Ir Med J. 2007 May;100(5):473-5


Abstract
Background: Nutritional supplements are prescribed to improve nutritional status, and reduce hospital stays in malnourished hospital patients. Clinical benefits are dependant on compliance, the level of which remains unclear. Aims To assess compliance levels with oral nutritional supplementation and determine methods to improve compliance. Methods Compliance was observed over 10 days by measuring total supplements prescribed and weighing wastage remaining after use. Areas for improvement were identified and implemented for 6 months. Specifically, a distinct supplement administration round was established and those patients requiring assistance with supplement consumption were identified with signage above their beds. Compliance was re-assessed in a sub sample of patients. Results Thirty seven elderly patients (mean age 85 years; 57% female) prescribed nutritional supplements were studied. Mean compliance was significantly greater in males than females (85.7% vs 74%) and acute wards compared to longstay (89.5% vs 74.2%). Compliance with supplements was significantly greater following intervention (mean 74.2% vs 93%, p < 0.0001). Conclusion Compliance with nutritional supplementation is variable among institutionalized geriatric patients. Timing of supplementation dispensation and improving staff vigilance can positively affect compliance.


Background
Drug and disease related loss of appetite combined with depression, impaired dexterity, impaired ability to chew or swallow and increased nutritional requirements due to infection, pain and discomfort result in geriatric patients becoming particularly vulnerable to malnutrition ¹. Oral nutritional supplements are frequently administered in hospitals to improve nutritional status and shorten hospital stays ².

Although nutritional supplements are widely used the level of compliance is still unclear ³. Lad et al examined compliance in 40 elderly stable patients prescribed nutritional supplements and explored the views of 16 patients and health professionals on factors influencing compliance in hospitalized and community patients ⁴. Compliance with sip-feed supplements was low in hospital and the community. Fifty seven percent of subjects consumed less than 80% of the prescribed quantity. Compliance was affected by flavour, taste, texture, personal preferences and lifestyle factors.

In addition several other investigations have reported poor or inconsistent compliance with prescribed nutritional supplements in both hospitalized and community dwelling cohorts of elderly patients ^{2, 5}.

The purpose of our study was to observe adherence to nutritional supplementation by elderly patients in both acute and long term care settings and to determine whether specific interventions improved compliance.

Patients and Methods
The study was conducted o n male and female patients in St. Mary’s Hospital between April and December 2005. St. Mary’s Hospital is a 321 bed geriatric care facility in North Dublin. Acute, respite and long-term care services are provided on the campus. All subjects prescribed protein/energy dense nutritional supplements were considered eligible.

Compliance with supplementation
Thirty seven patients were prescribed various types of protein/energy dense nutritional supplements including sip feeds and nutritional puddings. Normal hospital practice was adopted to prescribe supplements. A dietitian assessed patient’s requirements, medical conditions and taste preferences. Patients were informed of the benefits of nutritional supplements and encouragement was provided. As normal, nursing staff administered supplements during medication rounds during morning, afternoon and evening. Compliance was assessed by weighing the supplements prior to administration and weighing the discarded and partially consumed supplementary feeds when they were collected from the patients that evening. Data including patients gender, background, co-morbidities, weight (kg), height (estimated from knee height as many patients exhibited poor mobility) and other medications were recorded by the researcher. Normal hospital practice was observed throughout.

Intervention
Following the initial documentation of compliance notes, staff were interviewed on factors which they felt might affect compliance rates. Three areas for intervention were identified:

1. A supplement only round was introduced between the medication and meal rounds.
   
   
2. Signs that identified patients who require assistance eating were placed at beds
   
   
3. Staff were encouraged to actively promote taking the supplement opportunistically at all patient interactions throughout the day.

Changes were implemented on wards for 6 months and compliance was reassessed in 9 patients.

Statistical Analysis
Data was entered into spreadsheets (Microsoft Excel, version 97). Students t-test was used to compare means between the groups.

Results
Of the 37 patients at baseline, 16 were male and 21 were female. Age range was 74-97 years, mean age was 85 years. Nine of the patients were classed as acute, 28 were in long term care (average duration 4 years). Mean male weight was 55.9 kg (range, 45.2 – 70.0kg) and mean female weight was 53.0kg (range 32.7 – 67.5). Compliance rates were significantly higher for males (92% vs 74%, p<0.0001).

Compliance among female patients in acute wards was significantly greater compared to long stay wards (90% vs 74%, p<0.0001) (Figure 1). Consumption rates were directly proportional to ward staffing levels (r =……) ( figure 2&3).

Compliance with supplements was significantly greater following intervention (mean 74.2% vs 93%, p < 0.0001). Neither patient’s overall weight or BMI were affected significantly by the interventions, although both showed a trend towards increasing following the described interventions.

Discussion
Nutritional supplements are frequently used to improve nutritional status however benefits are dependent upon patient compliance ². This study aimed to establish levels of patient compliance and factors influencing compliance.

Compliance with supplements was high at baseline with males consuming 92% of supplements and females consuming 74%. This finding contradicts other studies in this area. Gosney studied compliance in 96 elderly patients. Compliance was found to be as low as 37% with factors such as low levels of thirst and unfamiliar drinks found to be responsible. Older patients did not like drinking from straws and were discouraged by frequent spills. Wastage was found to be as high as 72% among patients who were provided with flavours they did not like ³. This present study found wastage levels at baseline to reach up to 26% among female patients. This finding substantiates that of Nolan who found wastage to be in the region of 24 – 45% ⁶.

Compliance was greater in acute wards (90%) compared to long stay wards (74.2%). Patients admitted to acute wards come directly from the community and so are more likely to be independent in self care and self administration of supplements. Patients on long stay wards are highly dependent and required assistance with supplements.

Compliance was greater when staffing levels were higher. The majority of patients in the study were highly dependent on assistance from staff who reported that they had more time to spend with each patient when staffing levels were greatest. Following intervention staff were encouraged to actively promote supplement consumption opportunistically throughout the day. This enhanced staff awareness of unconsumed supplements. Additionally, signs were placed at the top of patient’s beds to remind staff which patients required assistance. Face- to face interviews concluded that this intervention was useful for temporary or new staff who did not yet have a thorough knowledge of each patient’s requirements or for a patient who had just been admitted.

The introduction of a supplement only round was useful in making staff more conscious of giving supplements and meant that patients were not provided with supplements and medications simultaneously. The round was introduced so that it would not interfere with meal times and nurses felt that dietary intake remained unchanged. This concurs with the finding by Turic et al who concluded that nutritional supplementation improves intakes of elderly patients in long-term care without replacing energy or nutrient intakes from the diet ⁷. Similarly, Boudville et al found that there was no significant difference in total intake between drinking a nutritional supplement 30 minutes or 2 hours before lunch ⁸. However, it was suggested that nutritional supplements may have replaced other fluids that would be dispensed around the same time.

There were limitations in the data collected for this study. Overall dietary intakes were assessed through observation only which may have resulted in subject error. Weights and knee heights were only recorded in the more stable patients (40%) and it was not possible to associate changes in anthropometric measurements with patient compliance. Measurement error was minimized by using the same instruments and researcher to collect the data.

Compliance with nutritional supplements is high in elderly patients in acute and chronic care settings but intakes can be significantly improved by increasing nursing awareness of patient requirements, opportunistic feeding and altered timing of supplement dispensation to a time between meal times and medication administration.

References

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