Key learning points:
– Understanding when a patient is dehydrated
– Knowing the importance of hydration in older patients
– Developing skills in nursing and care staff to identify older patients at risk of dehydration
Being well-nourished and well-hydrated is a core component of maintaining good health. But while there is a growing emphasis on tackling malnutrition and improving nutritional care, there is a danger that hydration is being overlooked.
Good hydration enhances feelings of wellbeing, reduces the use of medication and helps prevent illness. For most adults, dehydration is a problem with a quick fix. However for older adults, dehydration is the most common cause of fluid and electrolyte imbalance and one that can have devastating long-term effects.1 Therefore ensuring good practice in hydration care is key to improving quality of life and maintaining older people’s health.
It is well documented that many older people continue to suffer from preventable dehydration, even though it can be easily avoided by ensuring individuals have enough to drink. Despite this apparently simple and cost-effective preventative measure, dehydration is still a major problem for older people in care homes, hospitals and in their own homes within the community.2
Indeed recent research shows that patients admitted to hospital from care homes are commonly dehydrated on admission and are consequently at a significantly greater risk of in-hospital mortality.3
Evidence of poor practice
Many examples of poor hydration practice can be found. To cite just one, the Francis Inquiry Report into failings at Mid Staffordshire Foundation Trust concluded that: “some patients were left food and drink and offered inadequate or no assistance in consuming it, even water or the means to drink it could be hard to come by.”4
The issues raised in the Francis Inquiry Report are also fairly typical and the basic principles it proposes for improving hydration are equally telling: ensuring drinks are within reach; recording fluid balance accurately; delivering drinks in appropriate containers; and using systems to highlight patients who need assistance with hydration.
Causes of dehydration in older adults
Dehydration in older adults can occur for a number of reasons including both physiological and environmental factors.
As ageing occurs the water content of our bodies’ and our thirst decreases. People usually rely on thirst as a signal for needing to drink, for older people this may not be an accurate indicator of the body’s fluid needs. Equally, difficulties with swallowing, mobility and sensory impairment can create barriers to maintaining adequate hydration.
However there are a number of key risk factors that are not associated with the physical ability to drink. If older people have to rely on others to supply drinks then they will probably not be drinking enough. Understanding the patient and seeing the person behind the illness will help to maintain hydration. For example recognising that:
· Being admitted to hospital can increase disorientation and confusion particularly if there is impaired sensory perception and glasses or other aids are not to hand.
· Changes in functional mobility or poor oral health may cause difficulties in drinking.
· People who have dementia or cognitive impairment may not recognise thirst and need regular prompts that they can understand to remind them.
· Older people will often self-limit fluid intake for fear of incontinence or being a nuisance if they need help to use the lavatory bedpan or commode.
· Being lonely, afraid, or not understanding what is happening in a ward or care home can have a devastating effect on wellbeing and maintaining health.
· Knowing and offering what people like to drink will help to increase fluid intake.
Risks of dehydration
If mild dehydration is not recognised or is left uncorrected, the effects can be serious and rapid.5 Common consequences of dehydration include confusion, falls, pressure ulcers and UTIs. Dehydration can deteriorate rapidly and lead to unnecessary invasive clinical interventions and long-term outcomes that can result in the loss of independence, dignity and death.
Chronic dehydration also develops over time, which is why detailed, structured, standardised and regular assessments are needed.
Bridging the theory to practice gap
Achieving and maintaining good hydration in healthcare is complex and can often be complicated by pre-existing long term conditions.6 Bridging the theory to practice gap remains a constant challenge, and identifying and addressing why staff do not recognise dehydration is fundamental to improving practice.
There is clearly a role for improving training. Health and care assistants make up a significant proportion of the hands-on workforce and are often relied upon to observe and report subtle changes or concerns in patients and residents conditions. Yet clinical leads often wrongly make the assumption that training has equipped staff with an adequate theoretical and practical understanding of the importance of hydration.
It is reasonable to suggest that preventable dehydration can be regarded as a quality indictor of potential neglect and clinical leaders must do all they can to eliminate it.
The key to raising the profile of this and making hydration a priority, is strong consistent clinical leadership underpinned with policy’s processes and guidelines to tackle preventable dehydration. With that, nurses and care staff must be supported to develop the skills to identify people who are at risk of dehydration and have the skills to then document that risk in care plans.
But we must also recognise the need for a whole systems approach to raising awareness. It is vital that more information about preventing, recognising and tackling dehydration is made available to older people, families and carers as well as healthcare professional.
1. Hodgkinson B, Evans D, Wood J. Maintaining oral hydration in older adults: A systematic review. International Journal of Nursing Practice 2003;9(1):19-28 doi:10.1046/j.1440-172X.2003.00425.x (accessed 26 June 2015)
3. Wolff A, Stuckler M, McKee M. Are patients admitted to hospitals from care homes dehydrated? A retrospective analysis of hypernatraemia and in-hospital mortality. Journal of the Royal Society of Medicine. 2015.
4. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. 2013, p1600. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
(accessed 26 June 2015)
5. Begum M, Johnson C. Adequacy of Nutrient Intake Among Elderly Persons Receiving Home Care. Journal of Nutrition For the Elderly. 2008;21(1-2):65-82 doi:10.1080/01639360802059720
6. It is dangerous to think that ending dehydration is simple. 2013. www.nursingtimes.net/opinion/practice-comment/it-is-dangerous-to-think-t... (accessed 26 June 2015)
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