The move from a long-stay learning disabilitieshospital to community homes: a comparison of clients'nutritional status

F. Bryan,* T. Allan{ and L. Russell*

*Department of Nutrition and Dietetics, North Staffordshire Hospitals NHS Trust, Stoke-on-Trent; {Department of General Practice, The

University of Birmingham, UK

Abstract

Correspondence

Mrs F. Bryan,

Department of Nutrition and Dietetics,

North Staffordshire Hospitals NHSTrust,

Stoke-on-Trent, UK.

Tel.: +44 1782 552113

Keywords

learning disabilities, nutrition screening,

resettlement.

Accepted

May 2000

Background Adults with learning disabilities have a greater incidence

of health problems than the general population. It is now well

established that they are a nutritionally vulnerable group with polarized

weight distributions.

Aim This study was undertaken to investigate the nutritional

consequences of the closure of a large learning disabilities hospital

and the resettlement of clients in small community homes.

Methods The nutritional changes were measured using a locally

devised nutrition screening form. This had previously been tested for

reliability and validity.

Clients were screened in the month prior to their discharge from

Stallington Hall and at 1 year post-discharge. The two screening forms

for each client were then compared.

The screening form assessed risk in three areas: nutritional adequacy,

weight and nutrition-related problems.

Results A number of significant increases in risk between the two

screens were seen. In particular, there was an increase in overall risk

relating to food groups, unintentional weight gain and loss and overall

risk relating to weight.

At the first screen, 70% of the women and 55% of the men were

outside the normal weight ranges and by the second screen these

percentages had increased to 82% and 60%, respectively. It was not

possible to weigh 15% of the study participants at the second screen

because suitable scales were not available.

Conclusions The study confirms the nutritional vulnerability of the

participants and highlights a number of adverse nutritional changes. It

supports the need for regular screening and dietetic input.

Introduction

Traditionally, adults with learning disabilities were

placed in large long-stay institutions or hospitals.

The White Paper Better Services for the mentally

handicapped (Department of Social Security, 1971)

began to pave the way for an increase in community

care. Ten years later in the Care in the community

document (Department of Health and Social

Security, 1981) the government advocated the

closure of large-scale hospitals and their replace-

ment with ordinary homes in the community.

ã Blackwell Science Ltd 2000 J Hum Nutr Dietet, 13, pp. 265±270 265

The transfer from institutions to community care

has many implications in terms of quality of life,

type of care and health status.

The community move has many nutritional

implications ± meals are no longer cooked in a

central place by professional catering staff but are

cooked in the home by the carers and/or clients.

Clients have access to many new foods and are able

to buy their own foods and cook them. In the past,

clients may only have seen the cooked version of

foods, for example they may have seen scrambled

eggs but not a raw egg in its shell. The mealtime

environment will be different and there will be far

fewer people present. Clients may have free access to

food whenever they want it, rather than at set

mealtimes and snacks may be more readily avail-

able, for example biscuits in a tin or foods in a

fridge. The potential exists for many nutritional

changes, both beneficial and detrimental.

Adults with learning disabilities have been shown

to have a greater incidence of health problems than

the general population (Kerr et al., 1996.) In the

document A strategy for people with learning

disabilities (Department of Health, 1995) the need

for greater health promotion and surveillance was

recognized and a case made for routine screening to

detect problems, including those relating to nutri-

tion. It is now well established that adults with

learning disabilities are a nutritionally vulnerable

group.

This study aimed to investigate the nutritional

consequences of the closure of a large hospital in

North Staffordshire (Stallington Hall) and the

resettlement of clients into small community

homes. The method chosen to evaluate the changes

was nutrition screening. This study compares the

pre- and post-discharge nutritional status of 118

clients who were resettled from Stallington Hall

between 1996 and March 1998

Methods

Subject selection

All the study participants were adults, who were

originally living in staffed houses in a long-stay

hospital, Stallington Hall, and who were resettled

between October 1996 and March 1998.

Any clients who were resettled outside of North

Staffordshire were excluded from the study because

of the travelling distances involved. Any clients

whose resettlement was delayed because their new

home was not ready and were transferred to

temporary accommodation under the care of the

new providers were also excluded from the study.

Clients were resettled in a range of homes, some

being assessed as needing health care and some

needing social care. Care is provided by a range of

care providers ± some private companies and some

NHS Trusts and each care provider gave their

consent to the project.

Nutrition Screening Tool (NST)

A copy of the NST has been published previously

(Bryan et al., J. Hum. Nutr. Dietet. 11, 41±50, 1998).

The NST assesses risk in three areas: nutritional

adequacy of the diet (in terms of food groups),

weight and nutrition-related problems such as

swallowing difficulties or constipation. The first

two sections of the form (nutritional adequacy and

weight) involve a series of questions. If certain

answers are given, the `at-risk' column is ticked. For

the section on nutrition-related problems, the

person completing the form considers whether the

client is experiencing a number of problems such as

swallowing difficulties, which are placing them at

nutritional risk. If any of the boxes are ticked in this

section, the `at-risk' box is ticked. Thus for each of

the three areas the client is either allocated to the

`at-risk' or `not-at-risk' categories. If nutritional risk

is shown, further action is required such as the

formulation of a nutrition care plan.

The tool used had been devised locally and

piloted. It had also been previously tested for

reliability and validity (Bryan et al., 1998).

The screening process

The initial screening was completed by each

subject's named nurse, in the month prior to the

client's discharge from Stallington Hall. The nursing

staff were familiar with the tool as it had been in

routine use since 1993. Nursing staff used their

knowledge of each client and the nursing and

medical records to fill in the screening forms.

266 F. Bryan et al.

ã Blackwell Science Ltd 2000 J Hum Nutr Dietet, 13, pp. 265±270

Weights were obtained using locally available scales,

which included sit-on scales.

As the original validity testing showed the

assessment of weight to be the screening tool's

weakest part, each screening form was cross-

checked by a State Registered Dietitian with

experience in this type of assessment. A combina-

tion of methods were used for this, including

standard weight±height charts designed for the

general population, body mass index and a visual

assessment.

Rescreening took place 1 year after the client's

discharge. The NST was completed by the main

carer and again cross-checked by a State Registered

Dietitian, who visited the client in their home to do

this. The NST was completed within the period

1 month before and 1 month after the first

anniversary of the client's discharge. Again weights

were measured using locally available scales.

Sample size

A pilot study was conducted to determine the

necessary sample size and methods of statistical

analysis. The first 30 clients to have both screens

completed were included in the pilot study.

The pilot study showed that the sample size

required for the project was 120 clients, giving 90%

power, at a 5% level of significance.

Data entry

The data from each screening tool were coded and

entered into a Microsoft Excel spreadsheet. The data

were validated by randomly selecting study partici-

pants and then cross-checking that all their data had

been correctly entered. This was done by a Dietitian

who was independent of the study. The analysis was

carried out using the SPSS package.

Results

Characteristics of the study participants

The initial screening was carried out on 121 clients

and of these 118 proceeded to the second screening

stage and completed the study. Of the remaining

three clients, two died and the third did not wish to

co-operate with the second screening.

The study population consisted of 44 women and

77 men. Their learning disabilities ranged from mild

to severe and some also had challenging behaviour,

whilst others had physical disabilities.

The age ranges of the participants are shown in

Table 1.

Nutritional adequacy of the diet

The NST assesses the nutritional adequacy of the

diet by looking at whether clients are eating

adequate amounts from each of the food groups

and whether they are finishing a meal. For each

individual variable, McNemar's test was applied to

see if there were any significant shifts in the

numbers of clients at risk at the two screens but

there were no significant shifts.

Table 2 shows the relationship for overall risk

relating to nutritional adequacy at first and second

screening. McNemar's test showed that for all

subjects, there was a significant shift towards being

at risk from the first to the second screen

(P = 0.05). When men were considered separately

there was an increase in the number of those at

overall risk, between the first and second screening

(P = 0.008), and significantly more men had

difficulty finishing a meal (P = 0.039).

Table 1 Age ranges of study participants

Age range (years) Frequency (%)

Under 40 26 (22%)

40 and under 50 25 (20%)

50 and under 60 26 (22%)

60 and under 75 28 (23%)

75 and over 16 (13%)

Total 121

Table 2 Cross-tabulation of overall risk relating to nutritional

adequacy at screens 1 and 2 (n = 118)

Frequency Not at risk screen 2 At risk screen 2

Not at risk screen 1 68 (58%) 22 (19%)

At risk screen 1 10 (8%) 18 (15%)

Long-stay hospital vs. community homes 267

ã Blackwell Science Ltd 2000 J Hum Nutr Dietet, 13, pp. 265±270

Weight-related risk

Weight status as assessed by body mass index and

NST

The percentage of underweight (BMI , 20),

normal weight (BMI 20±25) and overweight (BMI

25 or more) at the first and second screens are

shown in Table 3 for those people who it was

possible to weigh. For some of the study partici-

pants it was not possible to weigh them at the

second screening, as they needed sit-on scales and

these were not available.

At the first screen, 70% of the women and 55% of

the men were outside the normal weight ranges. By

the second screen these percentages had increased

to 82% of the women and 60% of the men.

Unintentional weight changes

This section of the form looks at unintentional

weight changes. At the first screen it looks at

changes in the year prior to discharge and at the

second it looks at changes that have occurred in the

year following discharge.

Using McNemar's test, subjects showed a sig-

nificant shift towards unintentional weight loss and

unintentional gain between the two screenings

(P = 0.001 and P = 0.011). There were some

differences when men and women were considered

separately. Among women, McNemar's test showed

a significant shift in unintentional weight loss

(P = 0.041) only. However, amongst men, there

was a significant change both in unintentional

weight gain (P = 0.024) and in unintentional

weight loss (P = 0.015).

Among people who were assessed as having

normal weight at the first screening there was an

increase in the number at risk of both unintentional

weight gain (P = 0.001) and unintentional weight

loss (P = 0.007) at the second screening. Only three

of the 44 normal weight clients did not experience

any unintentional weight changes but they mainly

remained in the normal weight category.

Magnitude of weight changes

The magnitude of the weight changes was deter-

mined for males and females in each weight

category, as shown in Table 4. This showed a

tendency for the males to put on more weight than

females and to lose more weight except for those

who were overweight.

Overall risk relating to weight

Cross-tabulation relating overall risk to weight at

the screens is shown in Table 5. McNemar's test

showed a significant shift towards being at risk from

the first to the second screen (P = 0.009). The

number of men, but not of women, at risk overall

with regard to weight increased significantly

(P = 0.017) between the first and second screenings.

Nutrition-related problems

This section of the NST looks at whether a number

of nutrition-related problems are placing the client

at nutritional risk.

McNemar's test failed to identify any significant

shifts in these data overall. However, there was a

significant increase in the number of women with

difficulty chewing food at the second screen

Weight status

Males

Screen 1

(n = 75)

Males

Screen 2

(n = 70)

Females

Screen 1

(n = 43)

Females

Screen 2

(n = 34)

Total

Screen 1

(n = 118)

Total

Screen 2

(n = 103)

Underweight 12 11 19 26 14 16

Normal weight 45 40 30 18 40 34

Overweight 43 49 51 56 46 50

Table 3 Percentages of underweight,

normal and overweight clients at the

first and second screen (as assessed by

BMI)

Table 4 Magnitude of weight changes (kg) for males and

females in each weight category as defined at first screen.

Female Male

Category at screen 1

Underweight ± 5.9 to + 6.8 ± 8.5 to + 10.4

Normal weight ± 6.3 to + 6.1 ± 8.3 to + 24.4

Over weight ± 16.3 to + 9.8 ± 7.4 to + 14.3

268 F. Bryan et al.

ã Blackwell Science Ltd 2000 J Hum Nutr Dietet, 13, pp. 265±270

(P = 0.031). Significantly more men had psycholo-

gical reasons for altered food intake at the second

screening (P = 0.012)

Discussion

The study results confirm the overall nutritional

vulnerability of the study population and their

polarized weight distribution. A number of sig-

nificant increases in risk were seen, together with

varying patterns for men and women. Men were at

increased risk across a larger range of indicators

than women at the second screening.

The study showed that many of the clients

experienced unintentional weight changes. There

were a number of clinically significant large weight

changes and these were amongst the overweight

client group. Notably, three of the overweight

clients gained 9.5, 10 and 14 kg, respectively, and

three of the overweight clients lost 8, 9.5 and 16 kg.

It is alarming to note that 15% of the study

populations did not have access to suitable scales in

their community homes.

It appears from the study that many adverse

nutritional changes have occurred. However, it

must be remembered that the screening tool only

looks at a small number of areas. It does not, for

example, look at clients' views, client involvement

in choosing or cooking meals or the variety of

meals. Many significant improvements in these

areas and examples of good practice were seen, such

as clients choosing a meal, buying the ingredients

and helping to cook the meal. Some homes grow

herbs or fruit and vegetables in the garden.

Meal provision varied greatly in the homes, some

actually having a cook but in the majority of houses

staff and sometimes clients cook the meals.

It would be interesting to repeat the study at

intervals to determine whether the weight changes

stabilize or continue.

Conclusions

The study showed a high incidence of under

nutrition and obesity in the participants at both

screens. A number of adverse nutritional changes

were seen between the first and second screens,

particularly unintentional weight changes in the

normal weight clients.

It is recommended that screening continues on a

regular basis and that dietetic input to the

community homes continues.

Recommendations

As a result of the study the following recommenda-

tions are made:

1 There is a need to screen clients regularly to

detect nutritional risk and problems.

2 All clients should have access to suitable

weighing scales. The study has shown unintentional

weight changes do occur and it is essential that

clients are weighed regularly to detect any changes.

3 Dietetic input should continue in the commu-

nity homes.

4 For those hospitals beginning a resettlement

process, carers should be aware of the risks of

unintentional weight changes, particularly in the

normal weight clients.

Acknowledgments

The project was funded by a grant from the NHS

Executive, West Midlands. We would like to thank

the managers, carers and clients who helped with

this project. Thanks are also extended to Ann

Fennell and Victoria Blackshaw for their help with

data collection and validation and to Mairi Macleod

for typing the manuscript.

References

Bryan, F., Jones, J.M. & Russell, L. (1998) Reliability and

validity of a nutrition screening tool to be used with

clients with learning difficulties. J. Hum. Nutr. Dietet. 11,

41±50.

Department of Health. (1995) The Health of the Nation: A

strategy for People with Learning Disabilities. Wetherby:

Department of Health.

Department of Health and Social Security. (1981) Care in the

Table 5 Frequency of overall risk relating to weight at screens 1

and 2.

Not at risk screen 2 At risk screen 2

Not at risk screen 1 9 37

At risk screen 1 17 58

Total 26 95

Long-stay hospital vs. community homes 269

ã Blackwell Science Ltd 2000 J Hum Nutr Dietet, 13, pp. 265±270

community. A Consultative Document on Using Resources

for Care. London: DHSS.

Department of Social Security. (1971) Better Services for the

Mentally Handicapped. London: HMSO.

Kerr, M., Fraser, W. & Felce, D. (1996) Primary health care

for people with a learning disability, A keynote review. Br.

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270 F. Bryan et al.

ã Blackwell Science Ltd 2000 J Hum Nutr Dietet, 13, pp. 265±270