Resources for
Practice & Clinical Pharmacists
Malnutrition Pathway Primary Care Network Portal
PCN RESOURCES HOME PAGE RESOURCES A-Z RETURN TO MAIN SITEPrimary Care/Clinical Pharmacists take responsibility for medicines optimisation, reconciliation and providing expert advice on medicines. They undertake Structured Medicine Reviews (SMRs) with patients to proactively manage their inappropriate or complex polypharmacy needs.
Pharmacists are well placed to screen for malnutrition during SMRs and can offer patients first line advice on their nutritional status, monitor their progress, provide ongoing support and refer on to other members of the multi-disciplinary team such as a Dietitian as appropriate. They can also play an important role in prescribing or requesting Oral Nutritional Supplements (ONS) if indicated; reviewing prescriptions, encouraging concordance, and ensuring preferred flavours and formats are provided to optimise adherence and improve outcomes.
Actions for Consideration
Observe; build into conversations questions about any:
- New medicines or treatments
- Changes in appetite
- Unexplained weight loss
- Swallowing issues (dysphagia)
- Any fatigue
Further information can be found in our ‘Subjective indicators of malnutrition risk’ INFORMATION SHEET
Those patients where there is clinical concern for potential undernutrition should be screened using a validated tool, for example the BAPEN Malnutrition Universal Screening Tool, ‘MUST’, (a management pathway for Managing Malnutrition According to Risk Category using ‘MUST’ can be found HERE
Pharmacists should consider:
- How nutritional screening can be incorporated into practice in a timely and efficient manner - for example at a Structured Medicine Review, a Long-Term Condition Annual Review or an Older Person’s Health Check
- Working in conjunction with local Dietitians to encourage practices to integrate nutritional templates for specific patient groups, such as frail older people
- Regularly documenting patient weights and a height into electronic medical records to enable alerts for those who are ‘at risk’ of malnutrition
Consider the potential underlying causes of malnutrition:
- Identify anything that is interfering with the ability of the patient to eat and drink such as nausea, dental pain and address those that can be reversed or treated.
- A useful resource ‘Are there any symptoms/problems that you feel are affecting your ability to eat and drink’ can be accessed HERE
- Some medical treatments (e.g., chemotherapy) and medicines can have side effects which can impact on nutritional status, eating and drinking (e.g., laxatives, antidepressants)
- Speak to family, carers and care home staff about how they can support patients with their dietary intake
- Care homes might consider nominating a nutrition champion who can act as the local lead for nutrition screening and promote the use of nutritional care plans for residents. (Specific advice for care homes including sample care plans are available HERE )
- Liaise with the local dietetic department or refer to a Dietitian if patients have a specific diet-related medical condition such as diabetes or are having swallowing difficulties.
The Malnutrition Pathway has produced a useful list of questions and resources to help obtain information to assist in selecting the most appropriate course of action and dietary advice resources for the patient: ‘Initiating conversations about weight loss and diet’ GO TO RESOURCE SHEET
- Dietary advice leaflets providing further ideas on managing the diet-related problems/symptoms are available HERE Local guidance and advice sheets may also be available.
- It is important that patients understand the importance of adopting any dietary advice particularly if they have historically followed healthy eating plans and patterns. Some discussion regarding following a more calorific diet may need to be had along with advice on food fortification (A PATIENT INFORMATION SHEET CAN BE FOUND HERE) Those with eating and drinking difficulties should be referred on to other multidisciplinary team members such as Dietitians and Speech and Language Therapists
- Prescribe Oral Nutritional Supplements (ONS) for those identified at high risk. More information on prescribing ONS for healthcare professionals can be found HERE
- Discuss goals of the intervention with the patient and document on the patients notes and on any prescription issued so that the goal is clear to all parties involved in patient care. Examples of goals might include:
- Weight maintenance or weight gain
- Muscle gain, improved strength
- Improved mobility / ability to undertake activities of daily living
- Reduced infections
- Optimal recovery or healing (e.g., from surgery or pressure ulcers)
- Monitor progress against the agreed goals and with regular (monthly) reviews:
- modify intervention and adjust care according to patient / family / carer feedback
- consider weight, strength, physical appearance, mood, appetite, ability to perform activities of daily living and compare with the goal originally set / discussed
- Continue to monitor and make regular assessment of progress to check patient remains stable especially those in whom a medical condition can have a marked and sudden effect on intake (consider relapsing conditions e.g., Chronic Obstructive Pulmonary Disease (COPD), Irritable Bowel Disease (IBD). Consider using other members of the PCN to complete monthly reviews, e.g., Pharmacy Technician, Care Co-Ordinator
- Discontinue ONS when adequate oral intake is established, goals / targets have been met, factors that were contributing to malnutrition have been addressed and the patient is considered stable
- Carry out audits in practice to ensure patients are reviewed and prescriptions for ONS remain appropriate including checking compliance to ONS prescription ensuring that volume, format, type and flavour are appropriate for the patients’ needs.
- Where possible, liaise with local Dietitians / dietetic department about the potential training for support staff to carry out malnutrition screening and appropriately deal with requests for ONS
