RELEVANT DOCUMENTS TO SUPPORT THE CONTENT OF THE PRESENTATIONS OF THE WEBINAR

NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19

WATCH WEBINAR

The European Federation of the Associations of Dietitians

T H E V O I C E O F E U R O P E A N D I E T E T I C S

NEW

SFLASH

Special thanks to EFAD for their cooperation and support of the webinar

Chair biography: Prof. Jos MGA Schols

References

Speaker biography: Prof. Tommy Cederholm

Appendix I

Speaker biography: Maria Mckenna

Appendix II

Appendix III

Introduction by Nutricia

Practical resources

About Nutricia

About EFAD

CONTENTS

2NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19

INTRODUCTION BY NUTRICIA

Dear Webinar Attendees,

I am delighted to welcome you to this webinar hosted by Nutricia with special thanks to the European Federation of the Associations of Dietitians (EFAD) for their collaboration and support. The aim of this event is to empower healthcare professionals (HCPs) to optimize nutritional management in care homes, which is even more relevant in the current COVID-19 setting. In this webinar three excellent speakers will share their knowledge and experience relating to the nutritional challenges facing care home residents during the COVID-19 pandemic, current evidence on the importance of nutrition in this setting and the application of nutritional care pathways adapted to the COVID-19 context.

The COVID-19 pandemic has deeply affected care home residents, not only due to the direct impact of infection, but also due to the challenges of social isolation and reduced face-to-face care.

Much attention until now has been directed towards patients who have been hospitalized due to COVID-19 in the acute and post-acute phases. Through this webinar we want to add focus on care homes and the nutritional management of this very vulnerable population.

Whilst there is little evidence yet published on nutritional management of care home residents in the COVID-19 context, there is a wealth of information on nutrition in care homes in general. We believe that sharing and disseminating insights and learnings from experts in this field who have been intimately involved in research, patient management and development of guidance and care pathways is the best way to support optimization of nutritional care in this sector. This knowledge sharing will be of tremendous value to HCPs around the world.

3NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19

This booklet will introduce our speakers: Professor Jos Schols (The Netherlands), Professor Tommy Cederholm (Sweden) and Maria Mckenna (Ireland). At the end of this webinar you can expect to have gained the following insights:

• Awareness of the issue of malnutrition and of the impact of COVID-19 on nutritional status of care homes residents.

• Scientific evidence underpinning the role of optimal nutritional management in care homes

• Practical management of COVID-19 in the care home setting from a dietetic perspective based on a care pathway approach

If you are not able to attend the live event, the recordings of the webinar presentations, expert discussion, and questions and answers will be accessible by clicking on links in this booklet.

I hope you will enjoy this webinar and be able to apply some of the learnings to your daily practice.

With kind regards,

Ceri Green, PhD Medical Affairs Director Disease-Related Malnutrition and Frailty Nutricia Specialized Nutrition

4NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19

PRACTICAL RESOURCES

COVID-19 nutritional care pathways in care homes (Ireland)Nutrition Support Pack for Residential Care Facilities for Older People during Covid 19 (May 2020) See decision treeCOVID-19 Nutrition Care Pathway (Nutricia)

ESPEN guidelinesESPEN Guideline on clinical nutrition and hydration in geriatricsESPEN Guideline on clinical nutrition and hydration in geriatrics : A summary for clinical practice developed by NutriciaBarazzoni R, Bischoff SC, Breda J, et al. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection. Clin Nutr. 2020;39(6):1631-8.

Nutritional resources for older patientsNutrition and Dementia – a practical guide when caring for a person with dementiaMaking The Most of Every Bite – High Protein High Calorie Cookbook for Patients and their Carers

Resources on the role of medical nutrition for older patientsBetter care through better nutrition: Value and effects of Medical Nutrition” (2018)

Useful linksOptimal Nutritional Care for All (ONCA)Health Service Executive (HSE, Ireland)International Dysphagia Diet Standardisation Initiative (IDDSI)Irish Nutrition and Dietetic Institute (INDI)Irish Society for Clinical Nutrition & Metabolism (IrSPEN)

5NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19

PROFESSOR JOS MGA SCHOLSProf. of Old Age Medicine Maastricht University The Netherlands

Prof. Dr. Jos M.G.A. Schols is professor of Old Age Medicine. He works at the Department of Family Medicine and the Department of Health Services Research; CAPHRI, Maastricht University, The Netherlands. His main research topics are: 1) frailty and sarcopenia, 2) geriatric rehabilitation, 3) the epidemiology of and interventions for relevant health and care problems in chronic care and 4) transformation issues of chronic care. Schols is author of over 500 national and international publications and reviewer for a number of scientific journals and research funding agencies. He participates in several national and international boards, amongst which the Health Council of the Netherlands, an independent scientific advisory body for the Dutch government.

PROFESSOR TOMMY CEDERHOLMProf. Emeritus, Clinical Nutrition Senior Consultant Geriatrics Sweden

Prof. Cederholm is a Professor Emeritus of Clinical Nutrition, Uppsala University. He also serves as Senior Consultant, Head of R&D, Theme Ageing, Karolinska University Hospital, Stockholm, board certified in geriatric medicine and internal medicine. Research focus on catabolism in old and chronically ill subjects. Served as Executive Committee member of ESPEN 2012-2016. Member of the European Working Group on Sarcopenia in older people. Facilitator of the GLIM Criteria for malnutrition.

MARIA MCKENNAChair OPDIG-INDI Senior Community Dietitian Ireland

Maria Mckenna is chair of the Older Persons and Dementia Interest Group (OPDIG) of the Irish Nutrition and Dietetic Institute (INDI) and is a senior community dietitian in Dublin, Ireland. She has worked in both acute, rehabilitation and community dietetics over the past 10 years and has nine years experience working in nursing homes, residential units and day centres in both the National Health Service (NHS) in the UK and the Health Service Executive (HSE) in Ireland. Maria has a passion for improving nutritional care for people that live in residential settings with an Multidisciplinary Team (MDT) approach.

SPEAKERS

6NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19

The OPEN studyGrönstedt H, Vikström S, Cederholm T, et al. Effect of Sit-to-Stand Exercises Combined With Protein-Rich Oral Supplementation in Older Persons: The Older Person’s Exercise and Nutrition Study. J Am Med Dir Assoc. 2020; in pressFaxen-Irving G, Cederholm T, Grönstedt H, et al. Relationships between nutritional status, sarcopenia and frailty in nursing-home residents. Clin Nutr. 2018;37(Suppl 1):S59-S60 (Abstract)

Other references Faxen-Irving G, Cederholm T. Energy dense oleic acid rich formula to newly admitted geriatric patients - Feasibility and effects on energy intake. Clin Nutr. 2011;30(2):202-08.Tylner S, Cederholm T, Faxén-Irving G. “Effects on Weight, Blood Lipids, Serum Fatty Acid Profile and Coagulation by an Energy-Dense Formula to Older Care Residents: A Randomized Controlled Crossover Trial.” J Am Med Dir Assoc. 2016;17(3):275.e5-11. Liberman K, Njemini R, Luiking Y, et al. Thirteen weeks of supplementation of vitamin D and leucine-enriched whey protein nutritional supplement attenuates chronic low-grade inflammation in sarcopenic older adults: the PROVIDE study. Aging Clin Exp Res. 2019;31(6):845-54.

Appendix ICovid-19 Nutrition Support Pathway for Residential Care Facilities for Older Persons (HSE, V1, May 2020), page 3. Full version available here.

Appendix IINutricia COVID-19 Nutrition Care Pathway. Supported by

Appendix IIIESPEN Guideline on clinical nutrition and hydration in geriatrics: A summary for clinical practice developed by Nutricia

REFERENCES

7NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19

The full version of the pathway is available here

COVID-19 Nutrition Care Pathway for Nursing Homes Guidelines recommend that the prevention, diagnosis and treatment of malnutrition should be routinely included in the management of COVID-19 patients1. The aim of this pathway is to provide guidance, focused to those in the presence of older age and polymorbidity whom are at risk for poor outcomes following infection with SARS-COV-2.

Can the patient swallow safely?

Efficacy and expected benefit of ONS should be assessed

once a month.Have nutritional goals

been met?

Commence an ONS appropriate to the recommended IDDSI Level 125ml/200ml/125g BD

Nutilis Fruit Level 4

FortisipCompact Fibre

Nutilis Complete Level 3

Fortisip Extra

Commence Fortisip Compact Protein 125mls BD

Give dietary advice and encourage oral intake. Consider reducing ONS prescription for 2 weeks before stopping.

Seek advice of the dietitian. Check ONS compliance, amend prescription as necessary. WHEN TO STOP ONS PRESCRIPTION: Goals of intervention have been met and individual is no longer at risk,

if advised by dietitian or SLT, or if no further clinical input would be appropriate.

YesNo

*Please remember, your Nutricia Care Dietitians continue to be available at this time and referrals can be processed via a telephone dietetic assessment. Referrals to be sent to dietitianreferrals@nutricia.com or call

Freephone 1800 923 404 with any queries.

Patient with COVID-19 identified at risk of malnutrition using a validated screening tool e.g. ‘MUST’ screening toolNote: • Weighing residents may be more difficult at this time. Where possible continue to take weights on a monthly basis and use the opportunity to

weigh the resident when transferring from bed for dressing/washing to minimise physical contact and distress for the resident.• There is likely to be increased frequency of an “Acute Disease Effect’’ score within MUST screening with a diagnosis of COVID-19

(Acute Disease Effect score = If patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days).

Please commence a high protein high calorie diet. Dietitian referral recommended*. Agree goals of nutritional intervention.

Consider commencing oral nutritional supplements (ONS) when dietary counselling and food fortification are not sufficient to increase dietary intake and reach nutritional goals.

1. ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection (2020) available at https://www.espen.org/files/Espen_expert_statements_and_practical_guidance_for_nutritional_management_of_individuals_with_sars-cov-2_infection.pdf

This information is intended for Healthcare Professionals only. April 2020.Important Notice: All products shown are Foods for Special Medical Purposes for the dietary management of disease related malnutrition or dysphagia and must be used under medical supervision.

CL2220

No Yes

Level 1 Level 2 Level 3 Level 4

Supported by

Pa

rt I

Basic

que

stio

ns a

nd g

ener

al p

rincip

les (

all o

lder

peo

ple)

Pr

ovisi

on o

f ene

rgy

and

nutr

ient

s 1.

Gi

ve a

bout

30

kcal

/kg/

body

wei

ght/

day

2.

Give

at l

east

1 g

pro

tein

/kg/

body

wei

ght/

day*

3.

Us

e fib

re-c

onta

inin

g pr

oduc

ts fo

r ent

eral

nut

ritio

n (2

5 g

per d

ay co

nsid

ered

ade

quat

e)

4.

Give

micr

onut

rient

s acc

ordi

ng to

EFS

A or

nat

iona

l rec

omm

enda

tions

for h

ealth

y ol

der p

eopl

e un

less

th

ere

is a

spec

ific d

efici

ency

(cor

rect

with

supp

lem

enta

tion)

Or

gani

satio

n of

nut

ritio

nal c

are

5.

Scre

en a

ll* o

lder

peo

ple

with

a v

alid

ated

tool

to id

entif

y (ri

sk o

f) m

alnu

triti

on

6.

If ris

k of

mal

nutr

ition

is fo

und

unde

rtak

e sy

stem

atic

asse

ssm

ent,

indi

vidu

alise

d in

terv

entio

n,

mon

itorin

g an

d co

rres

pond

ing

adju

stm

ent o

f int

erve

ntio

ns

Esta

blish

stan

dard

ope

ratin

g pr

oced

ures

for n

utrit

iona

l and

hyd

ratio

n ca

re in

inst

itutio

nal s

ettin

gs.

Regu

late

resp

onsib

ilitie

s

*In

depe

nden

t of s

pecif

ic di

agno

sis a

nd in

cludi

ng o

verw

eigh

t and

obe

se p

eopl

e.

B

B

B

GPP

GPP

GPP

GPP

Perf

orm

ing

nutr

ition

al ca

re

8. P

erfo

rm in

divi

dual

ised

and

com

preh

ensiv

e nu

triti

onal

and

hyd

ratio

n ca

re to

: ✓

en

sure

ade

quat

e nu

triti

onal

inta

ke

✓

mai

ntai

n or

impr

ove

nutr

ition

al st

atus

✓

im

prov

e cli

nica

l cou

rse

✓

impr

ove

qual

ity o

f life

9.

Car

ry o

ut n

utrit

iona

l int

erve

ntio

ns a

s par

t of a

mul

timod

al a

nd m

ultid

iscip

linar

y te

am in

terv

entio

n to

: ✓

Su

ppor

t ade

quat

e di

etar

y in

take

✓

M

aint

ain

or in

crea

se b

ody w

eigh

t ✓

Im

prov

e fu

nctio

nal o

utco

me

✓

Impr

ove

clini

cal o

utco

me

10. I

dent

ify a

nd e

limin

ate

pote

ntia

l cau

ses o

f mal

nutr

ition

and

deh

ydra

tion

11. A

void

die

tary

rest

rictio

ns th

at m

ay li

mit

diet

ary

inta

ke a

s the

se a

re p

oten

tial h

arm

ful

A

B GPP

GPP

Part

III R

ecom

men

datio

ns fo

r old

er p

eopl

e w

ith sp

ecifi

c con

ditio

ns

Part

II R

ecom

men

datio

ns fo

r old

er p

eopl

e w

ith m

alnu

triti

on o

r risk

of m

alnu

triti

on

Supp

ortiv

e in

terv

entio

ns to

supp

ort d

ieta

ry in

take

12

. Offe

r mea

ltim

e as

sista

nce

to th

ose

with

eat

ing

depe

nden

cy

13. I

n in

stitu

tions

pro

vide

hom

e-lik

e pl

easa

nt d

inin

g en

viron

men

t (al

so su

ppor

ts Q

oL)

14. E

ncou

rage

shar

ed m

ealti

mes

(also

supp

orts

QoL

) 15

. Mea

ls on

whe

els s

houl

d be

ene

rgy

dens

e an

d/or

inclu

de

addi

tiona

l mea

ls

16. O

ffer n

utrit

iona

l inf

orm

atio

n an

d ed

ucat

ion

to p

atie

nt

17. P

rovi

de n

utrit

iona

l edu

catio

n to

HCP

s and

info

rmal

ca

regi

vers

Nu

triti

onal

coun

selli

ng to

supp

ort d

ieta

ry in

take

and

im

prov

e/m

aint

ain

nutr

ition

al st

atus

18

. Offe

r ind

ivid

ualis

ed n

utrit

ion

coun

selli

ng to

pa

tient

/car

egiv

er

19. I

t sho

uld

be d

eliv

ered

by

a qu

alifi

ed d

ietit

ian,

cons

ist o

f at

leas

t 2 in

divi

dual

sess

ions

whi

ch m

ay b

e co

mbi

ned

with

gro

up

sess

ions

, tel

epho

ne co

ntac

t and

writ

ten

advi

ce. M

aint

ain

over

a lo

nger

per

iod

of ti

me

(at l

east

8 w

eeks

) Fo

od M

odifi

catio

n to

supp

ort/

facil

itate

die

tary

inta

ke

20. O

ffer f

ortif

ied

food

**

21. O

ffer a

dditi

onal

snac

ks a

nd/o

r fin

ger f

oods

22

. Offe

r tex

ture

-mod

ified

, enr

iched

food

s to

thos

e w

ith si

gns o

f or

opha

ryng

eal d

ysph

agia

*G

rade

A fo

r ins

titut

ions

and

GPP

for h

ome

sett

ing.

**I

ncre

ases

ene

rgy

and

prot

ein

inta

ke, e

vide

nce

insu

ffici

ent t

o m

ake

reco

mm

enda

tions

on

food

fort

ifica

tion

with

m

icron

utrie

nts.

A/GP

P*

A GPP

B

B B B GPP

B GPP

GPP

Oral

Nut

ritio

nal S

uppl

emen

ts (O

NS)

23. O

ffer O

NS w

hen

diet

ary

coun

selli

ng a

nd fo

od fo

rtifi

catio

n no

t su

fficie

nt to

incr

ease

die

tary

inta

ke a

nd re

ach

nutr

ition

al g

oals

in

patie

nts w

ith ch

roni

c con

ditio

ns

24. O

ffer O

NS to

hos

pita

lised

pat

ient

s to:

✓

Im

prov

e di

etar

y in

take

✓

Im

prov

e bo

dy w

eigh

t ✓

Lo

wer

risk

of i

nfec

tion

✓

Lo

wer

risk

of r

eadm

issio

n 25

. Offe

r ONS

afte

r hos

pita

l disc

harg

e to

: ✓

Im

prov

e di

etar

y in

take

✓

Im

prov

e bo

dy w

eigh

t ✓

Lo

wer

risk

of f

unct

iona

l dec

line

26. O

NS o

ffere

d sh

all p

rovi

de a

t lea

st 4

00 k

cal a

nd ≥

30 g

pro

tein

/day

27

. ONS

shal

l be

cont

inue

d fo

r at l

east

1 m

onth

. Ass

ess e

ffica

cy a

nd

bene

fit o

f ONS

at l

east

onc

e a

mon

th

28. A

sses

s com

plia

nce

with

ONS

regu

larly

. Ada

pt ty

pe, f

lavo

ur, t

extu

re

and

time

of co

nsum

ptio

n to

pat

ient

’s ta

ste

and

eatin

g ca

pacit

ies.

GPP

A A A GPP

GPP

Ente

ral N

utrit

ion

(EN)

and

Par

ente

ral N

utrit

ion

(PN)

29

. Offe

r EN

if re

ason

able

pro

gnos

is an

d or

al in

take

ex

pect

ed to

be

impo

ssib

le fo

r >3

days

or <

50%

of

ener

gy re

quire

men

ts fo

r >1

wee

k de

spite

in

terv

entio

ns to

ens

ure

adeq

uate

ora

l int

ake

to:

✓

Mee

t nut

ritio

nal r

equi

rem

ents

✓

M

aint

ain

or im

prov

e nu

triti

onal

stat

us

30. E

valu

ate

expe

cted

ben

efits

and

pot

entia

l risk

s on

an

indi

vidu

al b

asis

and

re-a

sses

s reg

ular

ly a

nd w

hen

clini

cal

cond

ition

chan

ges

31. O

ffer c

omfo

rt fe

edin

g in

stea

d of

EN

whe

n in

take

low

in

the

term

inal

pha

se o

f illn

ess

32. I

f EN

indi

cate

d, st

art E

N w

ithou

t del

ay

33. U

se N

G tu

be w

hen

EN re

quire

d fo

r <4

wee

ks

34. U

se P

EG w

hen

EN re

quire

d fo

r >4

wee

ks o

r whe

n NG

no

t wan

ted

or to

lera

ted

by p

atie

nt

35. E

ncou

rage

mai

nten

ance

of o

ral i

ntak

e as

far a

s saf

ely

poss

ible

in tu

be fe

d pa

tient

s 37

. EN,

PN

and

hydr

atio

n ar

e m

edica

l tre

atm

ents

(not

ba

sic ca

re),

use

only

of t

here

is re

alist

ic ch

ance

of

impr

ovem

ent/

mai

nten

ance

of p

atie

nt’s

cond

ition

and

QoL

38

. Do

not u

se p

harm

acol

ogica

l sed

atio

n or

phy

sical

re

stra

int t

o m

ake

EN, P

N or

hyd

ratio

n po

ssib

le

39. S

tart

EN

and

PN e

arly

, gra

dual

ly in

crea

se o

ver f

irst 3

da

ys to

avo

id re

feed

ing

synd

rom

e 40

. Mon

itor b

lood

leve

ls of

P0 4

, Mg,

K a

nd th

iam

ine

over

fir

st 3

day

s of E

N an

d PN

in m

alno

urish

ed o

lder

pat

ient

s. Su

pple

men

t eve

n in

case

of m

ild d

efici

ency

GPP

GPP

GPP

GPP

GPP

GPP

GPP

GPP

GPP

GPP

Exer

cise

inte

rven

tions

in a

dditi

on to

nut

ritio

nal i

nter

vent

ions

41. E

ncou

rage

phy

sical

act

ivity

and

exe

rcise

to m

aint

ain

or

impr

ove

mus

cle fu

nctio

n an

d m

ass

GPP

42

. Pro

vide

ade

quat

e am

ount

s of e

nerg

y an

d pr

otei

n du

ring

perio

ds o

f exe

rcise

inte

rven

tions

to m

aint

ain

body

wei

ght a

nd

mai

ntai

n or

impr

ove

mus

cle m

ass

B

Adju

st a

ccor

ding

to in

divi

dual

nut

ritio

nal s

tatu

s, ph

ysica

l ac

tivity

leve

l, di

seas

e st

atus

and

tole

ranc

e.

Hip

fract

ure/

orth

opae

dic

surg

ery

Delir

ium

and

risk

of d

eliri

um

Depr

essio

n Pr

essu

re u

lcer/

risk

of

pres

sure

ulce

r Ov

erw

eigh

t or o

besit

y Di

abet

es M

ellit

us

ESPE

N Gu

idel

ine

on cl

inica

l nut

ritio

n an

d hy

drat

ion

in g

eria

trics

1 : A

sum

mar

y fo

r clin

ical p

ract

ice d

evel

oped

by

Nutr

icia*

1.

Volk

ert D

, Bec

k AM

, Ced

erho

lm T

, et a

l. ES

PEN

gui

delin

e on

clin

ical n

utrit

ion

and

hydr

atio

n in

ger

iatri

cs. C

lin N

utr.

2019

;38:

10-4

7.

*D

ocum

ent n

ot o

ffic

ially

end

orse

d by

ESP

EN

Reco

mm

enda

tions

sum

mar

ised.

See

gui

delin

e fo

r ful

l wor

ding

and

def

initi

ons o

f gra

des o

f evi

denc

e. N

ote

wor

ding

in g

uide

lines

as f

ollo

ws:

Gra

de A

= ‘s

hall’

, Gra

de B

= ‘s

houl

d’, G

rade

0 =

‘can

’ or ‘

may

’, GP

P =

base

d on

exp

ert o

pini

on, w

ordi

ng ch

osen

del

iber

atel

y.

Pa

rt IV

Rec

omm

enda

tions

to id

entif

y, tr

eat a

nd p

reve

nt d

ehyd

ratio

n in

old

er p

eopl

e Lo

w in

take

deh

ydra

tion

Fl

uid

inta

ke

61. O

ffer a

t lea

st 1

.6 L

of d

rink/

day

to o

lder

wom

en a

nd a

t lea

st 2

.0 L/

day

to o

lder

men

unl

ess t

here

is a

clin

ical

cond

ition

that

requ

ires a

diff

eren

t app

roac

h 62

. Offe

r a ra

nge

of a

ppro

pria

te (i

.e. h

ydra

ting)

drin

ks a

ccor

ding

to o

lder

peo

ples

pre

fere

nces

Id

entif

icatio

n of

low

-inta

ke d

ehyd

ratio

n

63. C

onsid

er ri

sk o

f low

-inta

ke d

ehyd

ratio

n in

all

olde

r peo

ple.

Enc

oura

ge co

nsum

ptio

n of

ade

quat

e am

ount

s of

drin

ks

64. S

cree

n fo

r low

-inta

ke h

ydra

tion

whe

n ol

der p

eopl

e ar

e:

• in

cont

act w

ith th

e he

alth

care

syst

em

• if

clini

cal c

ondi

tion

chan

ges u

nexp

ecte

dly

• m

alno

urish

ed o

r at r

isk o

f mal

nutr

ition

(scr

een

perio

dica

lly fo

r low

-inta

ke d

ehyd

ratio

n)

65. M

easu

re se

rum

or p

lasm

a os

mol

ality

to id

entif

y lo

w-in

take

deh

ydra

tion

66. U

se th

e cu

t off

of >

300

mOs

m/k

g (d

irect

ly m

easu

red

seru

m o

smol

ality

) to

iden

tify

low

-inta

ke d

ehyd

ratio

n 67

. Alte

rnat

ivel

y w

hen

dire

ctly

mea

sure

d se

rum

osm

olal

ity n

ot a

vaila

ble,

use

the

osm

olar

ity e

quat

ion

to id

entif

y lo

w-

inta

ke d

ehyd

ratio

n (o

smol

arity

= 1

.86

x (Na

+ +

K+) +

1.1

5 x g

luco

se +

ure

a +

14 (a

ll m

easu

red

in m

mol

/L) w

ith a

n ac

tion

thre

shol

d of

>29

5 m

mol

/L)

68. D

o no

t use

the

follo

win

g co

mm

on te

sts t

o as

sess

low

-inta

ke d

ehyd

ratio

n: sk

in tu

rgor

, mou

th d

ryne

ss, w

eigh

t ch

ange

, urin

e co

lour

or s

pecif

ic gr

avity

69

. Do

not u

se b

ioel

ectr

ical i

mpe

danc

e to

ass

ess h

ydra

tion

stat

us a

s it i

s not

dia

gnos

tical

ly u

sefu

l 70

. App

ropr

iate

tool

s may

be

used

by

olde

r peo

ple

and

thei

r inf

orm

al ca

rers

to a

sses

s flu

id in

take

. The

y sh

ould

ask

he

alth

care

pro

vide

rs to

ass

ess s

erum

osm

olal

ity p

erio

dica

lly

Trea

tmen

t of l

ow-in

take

deh

ydra

tion

71. E

ncou

rage

incr

ease

d flu

id in

take

from

pre

ferr

ed d

rinks

in o

lder

peo

ple

who

app

ear w

ell a

nd w

ho h

ave

mea

sure

d se

rum

or p

lasm

a os

mol

ality

>30

0 m

Osm

/kg

(or c

alcu

late

d os

mol

arity

>29

5 m

mol

/L)

72. O

ffer s

ubcu

tane

ous o

r int

rave

nous

flui

ds in

par

alle

l with

enc

oura

ging

ora

l flu

id in

take

in o

lder

adu

lts w

ho a

ppea

r un

wel

l and

who

hav

e m

easu

red

seru

m o

r pla

sma

osm

olal

ity >

300

mOs

m/k

g (o

r cal

cula

ted

osm

olar

ity >

295

mm

ol/L

)

B B GPP

GPP

GPP

B B A A GPP

GPP

A

73. C

onsid

er in

trav

enou

s flu

ids f

or o

lder

adu

lts u

nabl

e to

drin

k w

ith w

ho h

ave

mea

sure

d se

rum

or p

lasm

a os

mol

ality

>30

0 m

Osm

/kg

(or c

alcu

late

d os

mol

arity

>29

5 m

mol

/L)

Inte

rven

tions

to su

ppor

t old

er a

dults

to d

rink

wel

l and

pre

vent

low

-inta

ke d

ehyd

ratio

n 74

. Im

plem

ent m

ultic

ompo

nent

stra

tegi

es a

cros

s ins

titut

ions

for a

ll re

siden

ts

75. S

trat

egie

s sho

uld

inclu

de h

igh

avai

labi

lity,

var

ied

choi

ce a

nd fr

eque

nt o

fferin

g of

drin

ks

and

staf

f aw

aren

ess o

f the

nee

d fo

r ade

quat

e flu

id in

take

, sta

ff su

ppor

t for

drin

king

an

d in

taki

ng o

lder

peo

ple

to th

e to

ilet q

uick

ly w

hen

they

nee

d it

76. A

t reg

ulat

ory

leve

l, co

nsid

er m

anda

tory

mon

itorin

g an

d re

port

ing

by in

stitu

tions

of

hydr

atio

n ris

ks in

indi

vidu

al re

siden

ts a

nd p

atie

nts

77.

Reco

rd in

divi

dual

pre

fere

nces

for d

rinks

, how

and

whe

n se

rved

and

cont

inen

ce

supp

ort i

n ca

re p

lans

in in

stitu

tions

. Ass

ess i

ndiv

idua

l bar

riers

and

pro

mot

ers o

f dr

inki

ng.

78. E

xper

ienc

ed sp

eech

and

lang

uage

ther

apist

shou

ld a

sses

s, tr

eat a

nd fo

llow

up

olde

r ad

ults

with

sign

s of d

ysph

agia

. Mon

itor n

utrit

ion

and

hydr

atio

n st

atus

in co

nsul

tatio

n w

ith

spee

ch a

nd la

ngua

ge th

erap

ist a

nd d

ietit

ian

79

. Inc

lude

old

er p

eopl

e, st

aff,

man

agem

ent a

nd p

olicy

mak

ers w

hen

to d

evel

op st

rate

gies

to

supp

ort a

dequ

ate

fluid

inta

ke

Volu

me

depl

etio

n 80

. Ass

ess v

olum

e de

plet

ion

follo

win

g ex

cess

ive

bloo

d lo

ss u

sing

post

ural

pul

se ch

ange

fro

m ly

ing

to st

andi

ng (≥

30 b

eats

per

min

ute)

or s

ever

e po

stur

al d

izzin

ess r

esul

ting

in

inab

ility

to st

and.

81

. Ass

ess v

olum

e de

plet

ion

follo

win

g flu

id a

nd sa

lt lo

ss w

ith v

omiti

ng o

r dia

rrhe

a by

ch

ecki

ng a

set o

f sig

ns. A

per

son

with

at l

east

four

of t

he fo

llow

ing

seve

n sig

ns is

like

ly to

ha

ve m

oder

ate

to se

vere

vol

ume

depl

etio

n: co

nfus

ion,

non

-flue

nt sp

eech

, ext

rem

ity

wea

knes

s, dr

y m

ucou

s mem

bran

es, d

ry to

ngue

, fur

row

ed to

ngue

, sun

ken

eyes

. 82

. Old

er a

dults

with

mild

/mod

erat

e/se

vere

vol

ume

depl

etio

n sh

ould

rece

ive

isoto

nic

fluid

s ora

lly, n

asog

astr

ically

, sub

-cut

aneo

usly

or i

ntra

veno

usly

.

A B B GPP

GPP

GPP

B B B B

Part

III R

ecom

men

datio

ns fo

r old

er p

eopl

e w

ith sp

ecifi

c con

ditio

ns

Hip

fract

ure

and

orth

opae

dic

surg

ery

43. O

ffer O

NS p

osto

p to

: ✓

im

prov

e di

etar

y in

take

✓

re

duce

risk

of

com

plica

tions

44

. Do

not o

ffer s

uppl

emen

tary

ov

erni

ght E

N un

less

EN

indi

cate

d fo

r oth

er re

ason

s 45

. Pos

t op

ONS

may

be

com

bine

d w

ith p

erio

p PN

to:

✓

impr

ove

nutri

tiona

l in

take

✓

re

duce

risk

of

com

plica

tions

46

. Giv

e nu

tritio

nal

inte

rven

tions

as p

art o

f in

divi

dual

ly ta

ilore

d,

mul

tidim

ensio

nal,

mul

tidisc

iplin

ary

team

in

terv

entio

n to

: ✓

en

sure

ade

quat

e di

etar

y in

take

✓

im

prov

e cli

nica

l ou

tcom

es

✓

mai

ntai

n Qo

L

A

GP

P O A

Delir

ium

and

risk

of

delir

ium

47

. To

prev

ent d

eliri

um,

give

a m

ulti-

com

pone

nt

non-

phar

mal

ogica

l in

terv

entio

n th

at in

clude

s hy

drat

ion

and

nutr

ition

al

man

agem

ent t

o ol

der

patie

nts h

ospi

talis

ed to

ha

ve u

rgen

t sur

gery

48

. To

prev

ent d

eliri

um,

give

a m

ulti-

com

pone

nt

non-

phar

mal

ogica

l in

terv

entio

n th

at in

clude

s hy

drat

ion

and

nutr

ition

al

man

agem

ent t

o al

l old

er

patie

nts a

dmitt

ed to

a

med

ical w

ard

and

at

mod

erat

e to

hig

h ris

k of

de

liriu

m

49. I

n ho

spita

lised

old

er

patie

nts s

cree

n fo

r de

hydr

atio

n an

d m

alnu

triti

on a

s pot

entia

l ca

uses

or c

onse

quen

ces o

f de

liriu

m

A A GP

P

Depr

essio

n 50

. Scr

een

for

mal

nutr

ition

51

. Do

not r

outin

ely

give

nut

ritio

nal

inte

rven

tions

unl

ess

risk

of m

alnu

triti

on

or m

alno

urish

ed

GP

P O

Pres

sure

ulce

rs/r

isk

of p

ress

ure

ulce

rs

52. O

ffer n

utrit

iona

l in

terv

entio

ns to

old

er

peop

le a

t risk

of

pres

sure

ulce

rs (P

U)

to:

✓

prev

ent

deve

lopm

ent o

f PU

53

. Offe

r nut

ritio

nal

inte

rven

tions

to o

lder

pa

tient

s with

PU

to:

✓

impr

ove

heal

ing

B B

Over

wei

ght o

r obe

sity

54. A

void

wei

ght r

educ

ing

diet

s in

over

wei

ght o

lder

peo

ple

to:

✓

prev

ent l

oss o

f mus

cle m

ass

✓

prev

ent a

ccom

pany

ing

func

tiona

l dec

line

55. I

n ob

ese

olde

r peo

ple

with

w

eigh

t-rel

ated

pro

blem

s con

sider

w

eigh

t red

ucin

g di

ets o

nly

afte

r ca

refu

l and

indi

vidu

al w

eigh

ing

of

bene

fits a

nd ri

sks

56. I

f wei

ght r

educ

tion

is co

nsid

ered

in o

bese

old

er p

eopl

e,

rest

rict e

nerg

y on

ly m

oder

atel

y to

: ✓

ac

hiev

e slo

w w

eigh

t re

duct

ion

✓

pres

erve

mus

cle m

ass

57. I

f wei

ght r

educ

tion

is co

nsid

ered

in o

bese

old

er p

eopl

e,

com

bine

die

tary

inte

rven

tions

with

ph

ysica

l exe

rcise

to:

✓

pres

erve

mus

cle m

ass

GP

P GP

P GP

P A

Diab

etes

Mel

litus

58

. Scr

een

for m

alnu

triti

on

with

a v

alid

ated

tool

59

. Avo

id re

stric

tive

diet

s to

: ✓

pr

even

t mal

nutr

ition

an

d ac

com

pany

ing

func

tiona

l dec

line

60. M

anag

e m

alnu

triti

on

and

risk

of m

alnu

triti

on

acco

rdin

g to

the

reco

mm

enda

tions

for

mal

nour

ished

old

er p

eopl

e w

ithou

t dia

bete

s (se

e se

ctio

n II

abov

e/ov

erle

af)

GP

P GP

P

NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19 12

Since 1896, Nutricia has pioneered nutritional solutions that help people live longer, more joyful and healthier lives. Building on more than a century of research and innovation, Nutricia has harnessed the power of life-changing and life-saving nutrition to create a leading specialized nutrition portfolio that can change a health trajectory for life.

With its nutritional solutions, Nutricia supports healthy growth and development during the first 1000 days and helps to address some of the world’s biggest health challenges; pre-term birth, faltering growth, food allergy, rare metabolic diseases, age-related conditions and chronic disease, such as frailty, cancer, stroke and early Alzheimer’s disease.

As part of Danone, Nutricia embraces the company’s “One Planet. One Health” vision reflecting that the health of people and the health of the planet are interconnected and therefore seeks to protect and nourish both.

For more information visit: www.nutricia.com

ABOUT NUTRICIA

The European Federation of the Associations of Dietitians (EFAD) is the voice of 35,000 European dietitians in 29 European countries representing more than half the profession in Europe. Through its membership of 33 National Dietetic Associations and 38 Higher Education Institutes, EFAD aims to improve European nutritional health and reduce health inequalities among the populations its members represent.

Our Mission

To support member Associations in developing the role that dietitians have in the improvement of nutritional health in Europe.

Our Vision

EFAD, National Dietetic Association members (NDAs), Education Associate Members and dietitians are the recognised leaders in the field of dietetics and nutrition.

To achieve our vision, EFAD:

• supports the highest quality of dietetic education, professional practice, research activity and partnership

• pro-actively initiates and grows collaborations in order to improve nutritional health, reduce socio-economic health inequalities and contribute to economic prosperity.

Registered Address:

The European Federation of the Associations of Dietitians (EFAD) De Molen 93 3995AW Houten The Netherlands

Kamer van Koophandel (Chamber of Commerce in NL) registration number: 40215656

European Commission Transparency Register Identification number: 99138006725-91

Email: secretariat@efad.org

Website: www.EFAD.org

NUTRITIONAL MANAGEMENT IN CARE HOMES AND LEARNINGS FROM COVID-19

ABOUT EFAD

13