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Are care home residents more likely to be dehydrated?
According to new research published in the Journal of the Royal Society of Medicine, patients admitted to hospital from care homes are significantly more likely to be dehydrated than those admitted from their own homes. Equally serious was the reporting that such dehydrated patients are significantly more likely to die in hospital.
The study researchers from Barnet and Chase Farm Hospitals NHS Trust, the University of Oxford and the London School of Hygiene & Tropical Medicine reviewed the records of over 20,000 patient aged 65 years and over admitted to a London hospital trust for the first time over a two-year period (January 2011 to December 2013). The team obtained data on patients' ages, the type of admission (emergency or planned), and whether they lived in a care home or their own home. They also had information on whether the person was dehydrated when they were admitted to hospital and whether they subsequently died in hospital. The main analysis looked for links between whether a person was admitted from a care home and dehydration and death.
Why is dehydration dangerous?
Dehydration leads to high sodium levels in the blood, known medically as hypernatremia (plasma sodium of more than145 mmol/L). This measure, used as the marker for dehydration in the study, is a fairly accurate indicator of whether a person has had enough water or not. Certain conditions make hypernatremia more likely, such as prolonged vomiting or diarrhoea, sweating, and high fevers with inadequate replacement of the fluid lost. Hypernatremia can have severe consequences; in hospitalised patients it has been found to be associated with a greater risk of dying, increased risk of coronary events, pneumonia, thromboembolism and worse outcomes from stroke and kidney disease.
Dehydration in patients admitted from care homes with or without dementia was significantly higher than those admitted from their own home
The newly published study tested the hypothesis that patients admitted to hospital directly from care homes experienced increased risk of dehydration and therefore have higher in hospital mortality. Crude results reported from the study showed 1% of patients admitted from their own home were found to have high sodium levels, compared to 12% for patients admitted from care homes After adjustment for a number of possible explanatory factors, including age and dementia, the risk of high sodium levels was still over five times higher for those admitted from care homes. In fact, the lowest probability for dehydration on admission was observed for persons who were admitted from their own home, with no dementia (0.9%), followed by those with dementia (3.3%). A higher risk was found for persons admitted from care homes that did not have dementia (5.6%), with a significantly elevated risk in those who had dementia (14.7%).
The researchers also investigated the risk of hypernatremia on admission individually from the 53 care homes included in the study. This showed that admission from a care home is not inevitably associated with hypernatremia, but the probability is significantly increased. The study concludes that residency in certain care homes may increase the risk of hypernatremia and that hypernatremia on admission is an independent predictor of mortality. The high sodium levels in care home residents raises questions as to whether care home policies currently in place ensure that service users have adequate support for drinking, or whither these policies are being implemented.
Is inadequate care responsible for dehydration?
Reporting of the research in the media portrayed the dehydration as a result of staff restricting access to fluids so that residents were, for example, less likely to wet themselves during the night or ask for assistance in going to the toilet. However, this was only suggested anecdotally by the authors of the research, and anecdotal reports in terms of evidence-based medicine do not hold high value, and the real story is likely to be a little more complex.
If care home residents are dehydrated, there may be a number of possible reasons why. For example, service users themselves may intentionally choose to drink less because of difficulties in getting to the toilet. However, to date, this type of voluntary restriction has not been robustly studied.
Care home service users may be especially at risk if they require assistance with drinking and, left to themselves, they may fail to achieve adequate intake. Additionally, as suggested, care home staff may not offer water (or other fluids) in sufficient amounts as an active decision to reduce incontinence and frequent requests for assistance. The balance of these possibilities is not well understood. In fact, the authors, whilst speculating, did not investigate the reasons or provide any evidence as to why care home residents are more likely to be dehydrated. The analyses provided in the report do not take into account the reason why patients were admitted, which may have helped clarify the issue. An alternative explanation to inadequate care is that people in care homes may be more unwell or have more complex medical and care issues than people who live in their own homes which may influence their ability to remain hydrated. Moreover, this study was undertaken in a single NHS Trust, and as a result it is not possible to generalise these findings with certainty beyond the individual hospitals concerned and the care homes in the study population.
Does dehydration in patients admitted from care homes suggest a systemic problem?
Dehydration is often missed and a systematic tool for detecting it in care home settings is lacking. Often it is only detected in individuals once admitted to hospital, when electrolytes are measured. Sodium levels above 145 mmol/Lin a patient from a care home may be a trigger for concern, and perhaps should be expressed in the discharge summary to the GP responsible for medical care in that care home. The study authors also suggest a second admission with hypernatremia within a given period may well be indicative of a systemic problem in the care home, or that any care home from which more than a few patients are admitted to hospital with high sodium levels should potentially be highlighted to the Care Quality Commission (CQC). However, whilst this study is useful in flagging up potential care issues, it would need considerable further investigation to ascertain whether inadequate or inappropriate care is the core issue behind these findings.
Hydration is, and has for a long time been, a major issue with older people who live in care homes. Nutrition and hydration should be a core priority; with water and other fluids being readily available. Training for all our staff, should emphasise the importance of hydration. A follow up study may be useful to look at the impact of education of service users and carers in care homes and the active encouragement of fluid intake in care homes on dehydration status at admission.
Hydration is a basic need – it must be met.
Ayela Spiro, British Nutrition Foundation – QCS Expert Nutrition Contributor