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28th November 2015

Care for a drink?

Older people are particularly at risk of not drinking enough fluid, which can lead to dehydration. This is linked with a number of adverse health outcomes including poor wound healing, increased risk of falls and confusion. It can also lead to higher risk of drug toxicity and poorer quality of life.

It is not every day though that we can report on good studies that are directly applicable to the area of hydration in UK care homes, but let me give you an early Xmas treat by telling you about the Dehydration Recognition In our Elders (DRIE) research.

Some of the results from DRIE have recently been published and make interesting reading.  

DRIE study: Which frail older people are dehydrated?

The DRIE research group explored the conditions associated with dehydration. It is hoped that their results will help carers identify which older people in care homes may be most at risk of dehydration.  

The research took place across 56 care homes in Norfolk and Suffolk, where the team studied around  200 residents (mean age 86 years, 66% women).  The residents’ hydration status was determined by a serum osmolality blood test. This is the current ‘gold standard’ which assesses blood concentration, which becomes more concentrated when we drink too little. The researchers found a high prevalence (20%) of dehydration, suggesting that these residents were not drinking adequate amounts.

The DRIE researchers compared their hydration results, with a wide range of different cognitive, functional and health factors including whether or not they were continent, what medication they were taking and whether they had dementia. Those with diabetes, kidney problems and dementia were reported to be at most risk of dehydration. Factors including diuretic medication, gender (men), and bladder incontinence were also associated with dehydration.

Having a tool that can quickly and effectively identify dehydration would be a considerable benefit both to the health of residents. It would help to reduce the cost of dehydration related ill health to the NHS. However, there is a lack of understanding as to whether any simple tests, that are feasible to carry out routinely in care homes, are good at telling us whether service users are drinking enough.

Simple tests that have been suggested for the identification of dehydration have included:

  • Looking for dry mouth or lips;
  • Looking at whether skin feels dry;
  • Measuring skin turgor ( assessed by gently pinching skin and timing how long it takes to return to its pre-pinched position);
  • Looking at amount and colour of urine.

But are any of these tests effective?

DRIE study: How can we tell whether older people are drinking enough fluid?

The DRIE researchers recently published a review on useful tests for detecting dehydration. They found only a few studies that have looked at how well tests identify dehydration in older people, and that generally showed such tests were ineffective. Skin turgor, for example, may be ineffective as a tool because of skin ageing, which results in fluid loss becoming less linked to hydration status, and more to skin function (e.g. loss of fluid through perspiration).

Asking older people whether they miss drinks between meals could be helpful, but it is unclear as to whether this would provide a useful indication of dehydration. Asking older people whether they feel thirsty is also not a reliable test. Research indicates that the sensation of thirst becomes weaker with advancing age, with older people experiencing greater dehydration before thirst is reported.

The DRIE group wanted to see if they could find a more simple and non-invasive  method that correlated with the osmolality blood test, and so compared it to 3 simple tests (squeezing the skin, urine colour and dry tongues) to see whether they could distinguish between people who were drinking adequate amounts, and those who were not drinking enough.

However none of the tests looked at individually could reliably identify dehydration. Combining the tests may be more useful, and the efficacy of this approach is now being looked at in a follow-up study (DRIE2).

DRIE study: Increasing fluid intake and reducing dehydration risk in older people

The research team further carried out a systematic review looking at whether any interventions were effective in increasing fluid intake and reducing dehydration risk. They found 23 research papers from 7 countries that have looked at this. The majority of studies looking at multicomponent strategies described a positive effect. Components included greater choice and availability of drinks, increased staff awareness and increased staff assistance with drinking and toileting. A very small but interesting study showed improvement in fluid intake in men with Alzheimer’s disease using high contrast red cups.  However, studies that looked at modifications to the dining environment, advice to residents, presentation of beverages and mode of delivery (e.g. straw vs beaker or pre-thickened drinks vs drinks thickened at bedside) were inconclusive.

Whilst a wide range of interventions were identified by the researchers, the poor quality of the studies mean we cannot be certain with regards their efficacy. It does seem though that reducing the prevalence of dehydration in care homes is likely to require multiple strategies involving management and care staff.

Prevention and treatment of dehydration in care home residents is important

Finding simple ways to prevent and treat dehydration would seem particularly important in care home residents. One of the care homes involved in the DRIE study (with 20 residents all with severe dementia) has developed ways to try and keep their residents hydrated, as illustrated below.

  • Encourage high fluid intake early in the day;
  • Establish good drinking routine;
  • Be generous in provision of drinks;
  • Early recognition of urinary tract infections;
  • Ensure comfortable upright  sitting position;
  • Monitoring diuretics
  • Identifying with family members on admission likes and dislikes, and ensure preferences are available;
  • Checking continence pads;
  • Extra fluid provision in summer.

One of its key strategies is ensuring all residents drink well in the morning when they appear more awake and alert, and keen to drink. A nurse and two other members of staff work in the dining room every morning to support nutrition and hydration. The residents are encouraged to drink at least a litre of fluid that can include water with medication, tea, coffee, fruit juice, porridge, supplements and high protein milk with cereals. It is also a sociable time, where staff and residents interact, and staff undertake talking therapy. Hydration is a whole staff team initiative, and all staff, including domestic assistants, are involved in fluid care planning .

Although outcomes have not been robustly reviewed, care home staff say that since the hydration strategy was introduced, the general atmosphere in the home has improved and it has helped to reduce health problems.

Maybe we could learn something from them?

Ayela Spiro, British Nutrition Foundation – QCS Expert Nutrition Contributor

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