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Water Water Everywhere… But Dehydration Still a Problem in our Elderly
Nutrition and Hydration week, taking place from 17th - 23rd March 2014 recognises that nutrition and hydration are an important part of quality care, experience and safety improvement in health and social care settings.
While hospital food and malnutrition is often in the news, dehydration is also an important concern. Preventable dehydration in care settings, whether residential or hospitals is an indicator of poor quality care. And whist it may be preventable it would seem that it is still too common in the older person. Improving hydration can bring well-being and better quality of life for patients, allow reduced use of medication and prevent illness.
You can find out more about hydration and access the BNF healthy hydration guide at http://www.nutrition.org.uk/healthyliving/hydration/healthy-hydration-guide
Risk factors for dehydration
Older people are vulnerable to dehydration due to physiological changes in the ageing process, but this can be complicated by many disease states, and mental and physical frailty that can further increase risk of dehydration.
Age-related changes include a reduced sensation of thirst, and this may be more pronounced in those with Alzheimer’s disease or in those that have suffered a stroke. This indicates that thirst in older people may not be relied on as an indicator of dehydration.
Reduced renal function is also a risk factor. The kidneys play a vital role in fluid regulation but their function deteriorates with age, and the hormonal response to dehydration (which is key to fluid balance) may be impaired.
Dehydration is more common in those with cognitive impairment and changes in functional ability. Swallowing difficulties, dementia and poorly controlled diabetes are more common in older people and are all associated with poor hydration.
The likelihood of dehydration may also be exacerbated by medications including diuretics and laxatives. Importantly incontinence predisposes to dehydration as people may limit their fluid intake.
Inadequate fluid intake is a major contributor to preventable dehydration. Poor oral intake of fluids can be related to the inability to feed independently and having poor availability and access to fluids. This can be exacerbated in the residential care setting by inadequate staff training and lack of awareness of the importance of hydration.
Common risk factors for dehydration
• Older age
• Residing in long term care
• Requiring assistance with foods and fluids
• Cognitive Impairment/Confusion
• Impaired functional status and assistance required for feeding
• Inadequate numbers or appropriately trained staff to assist
• Multiple medications particularly diuretics
• Decreased thirst
• Acute illness, diarrhoea and vomiting
Consequences of dehydration
Dehydration is associated with poor health outcomes such as increased hospitalisation, and mortality; for example a two-fold increase in the mortality of stroke patients has been reported.
Even mild dehydration adversely affects mental performance and increases feelings of tiredness. Mental functions affected include memory, attention, concentration and reaction time.
Common complications associated with dehydration also include low blood pressure, weakness, dizziness and increased risk of falls,
Poorly hydrated individuals are more likely to develop pressure sores and skin conditions,
Water helps to keep the urinary tract and kidneys healthy. When fluid intake is reduced the risk of urinary tract infections increases. Inadequate hydration is one of the main causes of acute kidney injury
Inadequate fluid intake is also one of the most common causes of constipation. In individuals who are not adequately hydrated, drinking more fluid can increase stool frequency and enhance the beneficial effect of fibre intake.
Many older people are reluctant to drink to avoid the need to go to the toilet, particularly at night, but restriction of overall fluid intake does not reduce urinary incontinence frequency or severity.
Signs of dehydration
Signs of dehydration include dryness of the mouth, lips and tongue, sunken eyes, dry inelastic skin, drowsiness, confusion or disorientation, dizziness and low blood pressure. Many of these signs are rather subjective and can present in other conditions.
Dehydration is also indicated with a reduced and more concentrated urine output. As a general rule, the colour of urine can be a useful guide; urine that is odourless and pale in colour generally indicates good hydration, dark strong smelling urine is a common symptom of dehydration. However, there are a number of medical conditions and certain medications that can add colour to urine.
Monitoring fluid intake is a good guide to ensuring good hydration.
What can be done to prevent dehydration?
There are a variety of potential ways to help older people reduce their risk of dehydration. Recognising when the older person is not drinking enough and helping them to drink more is important.
Strategies to increase fluid intake in residential care homes include identifying and overcoming barriers to drinking, such as being worried about not reaching the toilet in time, physical inability to make or to reach drinks, and reduced social drinking and drinking pleasure.
A recent systematic review found that preventing dehydration in elderly care home residents is multifactorial. Increasing assistance as well as increasing the choice and availability of drinks and type of receptacles in which they are served may be helpful.
Strategies may include
• Staff training to recognise the importance of hydration.
• Determine an individualised daily fluid intake goal
• Provide preferred fluids
• Have fluid available at all times
• Make sure water is fresh and looks palatable — perhaps by adding a few slices of lemon or orange or ice cubes.
• Offer fluids regularly throughout the day
• Offer fluids at routine events such as before physiotherapy or other activity or medication rounds
• Offer a variety of hot and cold fluids
• Provide assistance if required
• Provide aids for drinking if needed such as special cups
• Offer at least a full glass of fluid with medications
Other strategies to increase fluid intake can be providing a ‘happy hour’, encouraging families and visitors to offer fluids and encouraging wet foods such as pureed fruit, yogurt, jelly, custard and soup
Medical and care staff and carers should be aware of the causes of dehydration in older people and understand how to maintain adequate hydration and to recognise the signs and symptoms of dehydration
It is also important to recognise that Care Quality Commission Standards apply to hydration as well as nutrition and focus on identification and assessment, monitoring fluid intake and care. These include:-
• Staff identify when a person is at risk of dehydration
• Those identifies as at risk have their fluid intake monitored
• Hydration requirements are identified and reviewed, and communicated
• The care plan identifies how the risks will be managed
• Patients can be confident staff will support them to safely meet their drinking needs
Maybe your goal for this nutrition and hydration week can be to increase your awareness of the importance of hydration. It can make a difference to health and quality of life.
Ayela Spiro, British Nutrition Foundation – QCS Expert Nutrition Contributor