‘Water, water everywhere’; dehydration in the older population

Janet Gordon & Marie Henson both work for Birmingham Community Healthcare NHS Foundation Trust. Janet Gordon is a dietitian working in Nutrition Support and is team leader for the adult Nutrition Support Team which is part of Birmingham Community Nutrition. At the time of the study Marie Henson was a Community Nurse team leader in the Kings Heath area of Birmingham, which is where the study took place. This study was presented as a poster at BAPEN Conference 2016 and was published here.

The prevalence of dehydration in older people in the UK has not been widely studied. The UK DRIE Study found 20% of residents in UK long term care were dehydrated. The prevalence in those living at home has not been determined. Dehydration in older people is linked to associated morbidities such as increased falls, confusion, and infections and is a frequent cause of hospitalisation. Clear signs of early dehydration in older people are yet to be determined, but there is a need to identify those at risk of dehydration and intervene early. Systems for recognising those with inadequate fluid intakes, and helping them to drink more, are already in place in many UK hospitals where a red jug scheme identifies those requiring assistance to drink. The use of a hydration screening tool in UK hospitals to determine those at risk of dehydration is in its infancy with limited tools available and any yet to be validated. The aim of this pilot study was to adapt one such tool (‘GULP tool’: Permission given – Food First team, South Essex Partnership University NHS Foundation Trust) for use in patients’ homes by community nurses to determine the risk of dehydration and, if at risk, to give advice to increase fluid intake including the provision of a red jug to act as a prompt for the patient/carer.

All new patients and any ongoing patients felt to be at risk of dehydration, on the caseload of two community nurses, were selected over a period of 6 months. The adapted ‘GULP’ tool (fluid requirement calculated, current fluid intake estimated and compared to requirement, urine colour assessed, physical signs of dehydration checked) was completed and a score generated. A medium or high-risk score prompted a care plan for the intervention to be put in place with the patient/carer. The intervention included placing a red jug for cold drinks in line of sight and making it easy to reach, giving verbal advice to drink more, completing a fluid intake chart for 1 week and providing a written advice card. The ‘GULP’ tool was completed again 4–6 weeks after the initial screening and an evaluation form completed by the patient/carer and the nurse involved.

43 patients (range 73–100 years) were initially screened. The level of dehydration risk found was 6/43 low, 35/43 medium and 2/43 high risk. Of the 37 patients requiring the intervention 4 declined the red jug (2 preferred to use their own jug and 2 accepted verbal advice only). 17/43 patients were not rescreened due to no reason given (8), deceased (7), hospitalised (1), discharge from community nursing (1). Of the 26/43 patients that completed the pilot, 20 were at risk of dehydration initially (19 medium, 1 high risk). 16/20 reduced their risk score with 12 dropping to low risk, for 4/20 the level of risk remained the same with 3 of these being totally non-receptive to the intervention. All 6 patients that were low risk initially remained low risk. Fluid intake increased significantly as a result of the intervention with a mean increase in fluid intake of 615 ml/day (250 – 1050 ml/day) p<0.001 Pre-intervention the estimated fluid requirement was met by 73% compared to 94% post-intervention (p <0.001), with 11 patients exceeding their requirement. Those patients that benefitted the most were those living independently or those reliant on carer calls. For the 16 patients whose risk score was reduced they felt that the verbal advice and red jug had helped them the most, and all 16 stated they were more aware of the importance of drinking enough fluid and all had a drink within reach when the nurse visited. The nurses felt the tool was accurate in the risk score generated and felt that the 23/26 patients completing the pilot had benefitted with improvements seen in levels of alertness, urinary catheter-related problems, constipation and level of confusion. Regarding future use of the intervention the nurses felt that it should not be mandatory to complete for all referrals into community nursing, but just used for those deemed more at risk of dehydration. This would include patients with urinary catheters, those who live independently with problems mobilising and/or functional deterioration or reliance on carers, evidence of falls or pressure ulcers, those on thickened fluids and those that are of clinical concern.

It is apparent from this study that screening and raising the risk of inadequate fluid intake with older people can improve fluid intake with beneficial outcomes. We would urge all community care services to consider using a tool such as this.

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