water for wellbeing · (tortora and derrickson 2010). water is critical to many bodily functions -...

VICTORIAN CONTINENCE RESOURCE CENTRE

VCRC

WATER FOR WELLBEING A resource kit to promote adequate fluid intake for the older person

WATER FOR WELLBEING2 ACKNOWLEDGEMENTS

The Victorian Continence Resource Centre (VCRC) is a not-for-profit organisation that aims to promote continence for all people living in Victoria. We are the Continence Foundation of Australia Victoria Branch, the peak body for bladder and bowel health. Our aim is to raise awareness about bladder and bowel control problems, management and treatment options, and where to get help. The VCRC reaches out to a wide demographic that is ethnically, gender, age, socio economically diverse through a range of educational activities and events.

This resource kit has been developed to assist Home and Community Care Providers (HACC) and Residential Aged Care Facilities (care managers, health professionals, assessment staff, care workers and informal carers). The aim of the kit is to promote the benefits of adequate fluid intake for frail older people and to develop hydration practice that is evidence informed. The work has been led by the Victorian Continence Resource Centre, Continence Foundation of Australia Victoria Branch.

The assistance of representatives of the following organisations, who formed the original project advisory group and provided input to the concepts and development of the materials is greatly acknowledged: Cabrini Residential Care Ashwood, City of Banyule, Department of Human Services Aged Care Branch, Doutta Gala Community Health Service, Royal District Nursing Service and St.Georges Hospital. Excerpts from the ‘Water for Healthy Ageing: Hydration Best Practice for Care Homes’ toolkit are reproduced with the kind permission of Water UK.

In this 2nd edition, we would like to acknowledge the ongoing support and contributions of Amanda Kingham, Cabrini Residential Care Ashwood; Sue van Buuren, Salford Park Community Village; and Martin Knapp, Renal Physician.

ACKNOWLEDGMENTS

Introduction 4

About the resource kit 5

Aboutwaterandthebody 6

How fluid is lost from the body 6

Recommended fluid intake for the older person 6

Health benefits of adequate fluid intake 6

Dehydration 8

Signs of dehydration 9

Why the older person is at risk of dehydration 9

Watermythsandfacts 10

Strategiesonhowtoencourageadequatefluidintake 12

Monitoringhydrationstatusandfluidintake 14

Recommendationsforhydration 15

References 16

Appendix 18

CONTENTS

3 CONTENTS WATER FOR WELLBEING

4 INTRODUCTION WATER FOR WELLBEING

5 INTRODUCTION WATER FOR WELLBEING

Drinking adequate amounts of fluid is essential for health and wellbeing.

Almost every bodily function requires water: breathing, digestion and absorption of nutrients, waste removal and temperature control are just a few examples of how the body uses water.

Many frail older people are not drinking sufficient fluid to maintain adequate hydration. As a result, dehydration is common in older adults living in residential care facilities and those living in the community.

The consequence of not drinking sufficient fluid can lead to poor health outcomes such as constipation, poor oral hygiene, urinary tract infections, and may be a factor in hospitalisation. These health problems are often perceived as minor issues but for the individual, dehydration can have a significant impact on their quality of life.

The purpose of the Water for Wellbeing resource kit is to provide community and residential aged care services with tools to assist the implementation of hydration practice that is, where possible, evidence-informed thus improving health outcomes and quality of life for clients and residents.

ABOUT THE RESOURCE KIT

Water for Wellbeing offers a range of resources, written for the older person, care workers, informal carers and health service providers. We encourage you to read all the material within the kit and identify those resources that best suit your care setting. You may wish to mix and match the tools in other combinations to the ones we have suggested. We in fact hope you will find more creative ways of using the tools to enable good hydration practice in your care setting.

In this second edition, we have revised and updated the evidence base, with only some minor changes. Consequently, the tools have been revised and the number of tools have been reduced to create a more user-friendly and practical resource.

Throughout the kit we use the terms water and fluid interchangeably. This is done deliberately as water is the preferred drink and all other fluids are at least 80% water (Popkin, D’Anci and Rosenberg 2010). We make recommendations on the types of fluids that can be offered freely and those that should be limited.

ABOUT WATER AND

INTRODUCTION

Important: the kit is a general guide only and may not be suitable for individuals on fluid restrictionsdue to specific health problems and illnesses.

WATER FOR WELLBEING6 ABOUT WATER AND THE BODY

On average, our bodies are 60% water and it is the primary component of all bodily fluids - blood, lymph, digestive juices, urine, tears and sweat (Tortora and Derrickson 2010). Water is critical to many bodily functions - circulation, digestion, absorption and the elimination of wastes to name a few. Water carries electrolytes (mineral salts) that help convey electrical currents in the body; the major elements that make up these salts are sodium, potassium, calcium and magnesium. Water is one of the six nutrients vital for life; the others being carbohydrates, proteins, minerals, vitamins and lipids.

HOW FLUID IS LOST FROM THE BODYAll persons breath, sweat, pass urine and faeces. The fluid lost, known as obligatory loss, must be replaced to maintain the water content in the body. On average a person loses around 2.5 litres of fluid each day. An inactive older person’s fluid loss may be closer to 2 litres per day. Fluid is lost in the following ways (Tortora and Derrickson 2010):

Breathing 300 mL

Sweating 600 mL

Urine output 1500 mL

Faeces 100 mL

Physical activity and a hot environment further increases the amounts of fluid loss, through an increased breathing rate and excessive sweating. In residential aged care, the ambient temperature

is around 25°C, thus loss from sweating will be similar for residents throughout the year. It is also important to remember to maintain fluid intake in the colder months. If an individual has diarrhoea or vomiting then fluid loss will also increase.

RECOMMENDED FLUID INTAKE FOR THE OLDER PERSONAdequate intake of ‘total water’ comes from the combined intake from drinking water, other beverages and food sources. Approximately 60% of total water intake comes from fluids, 30% comes from moist foods and the remaining 10% is produced by the body’s metabolism (Tortora and Derrickson 2010). Optimal daily fluid intake depends on various factors including weight, health status and energy expenditure, therefore; there is no single recommended daily intake (RDI) for adults (Godfrey et al 2012).

The current guidelines suggest a minimum of 1500ml of fluid daily for an older person (Mentes 2006).

HEALTH BENEFITS OF ADEQUATE FLUID INTAKETo maintain health everyone needs to drink well and maintain fluid balance. Fluid balance meaning that fluid intake equals output (Mentes 2006). Some of the health benefits of adequate fluid intake and problems of inadequate fluid intake for the older person are summarised below.

ABOUT WATER AND THE BODY

WATER FOR WELLBEING7 ABOUT WATER AND THE BODY

Bladderhealth: Maintaining adequate fluid intake is important for the health of the bladder. Many older people limit their fluid intake in an attempt to prevent urinary incontinence or the need to go to the toilet overnight, known as nocturia. This strategy has little or no effect on these bladder symptoms and may worsen for some individuals (Gray and Krissovich 2003; Townsend et al 2011).

Urinarytractinfections(UTIs)are common in residential aged care. Reduced urine flow from inadequate fluid intake is one factor that puts the older person at greater risk of developing UTIs. Adequate fluid intake is therefore an important strategy in reducing UTIs in residential aged care (Ruxton 2012; Whitehead 2009).

Bowelhealth: Adequate fluid intake is one simple measure that reduces any tendency for ‘dehydrated’ hard stools and constipation. In conjunction with dietary fibre, adequate fluid intake can increase stool frequency and improve stool consistency, making bowel motions easier for the older person (Ruxton 2012).

Bloodpressure: Many older people upon sitting or standing, experience lowered blood pressure (postural hypotension) which may cause a fall and loss of consciousness. Lu et al (2003) suggests drinking a glass of water before sitting or standing helps to prevent this change in blood pressure and reduces the risk of fainting. There are many other causes of postural hypotension, these include blood pressure medications, diuretic therapy, diabetic neuropathy and adrenal dysfunction.

Cognitivefunction: Cognitive function progressively deteriorates as the level of dehydration increases. Common symptoms of mild dehydration include headache, irritability, poor concentration and reduced alertness (Wilson and Morley 2003; Rogers, Kainth and Smit 2001). Once thirst is felt cognitive performance may be affected by up to 10% (Rogers, Kainth and Smit 2001). In an older person this loss of cognitive function impacts on any existing functional impairments and increases their levels of dependency, reducing their quality of life (Wilson and Morley 2003).

Skinandtissues: Well hydrated skin and tissue is more resilient to tears and to the effects of pressure, thus reduces the risk of pressure ulcers (Little 2012; Ruxton 2012). Good hydration may also improve healing (Benelam and Wyness 2010).

Fallsprevention: Older people have an increased risk of falls. Tzeng and Yin (2012) found that dehydration was one of the major preventable risk factors for falls in acute care settings. The cognitive changes (poor concentration and reduced alertness) and lower blood pressure (fainting and feeling dizzy) increases the person’s risk of a fall (Mentes and Culp 2003).

DEHYDRATION

8 DEHYDRATION WATER FOR WELLBEING

Many frail older people living in residential aged care and also those living within the community do not maintain a fluid intake adequate to avoid dehydration (Bennet, Thomas and Riegel 2004; Shimizu et al 2012).

Dehydration results when more fluid is lost from the body than is taken in. The consequence of not drinking sufficient fluid can cause rapid deterioration in the health of the older person, resulting in hospitalisation. However, the majority of frail older people drink just enough fluid to prevent acute dehydration but not sufficient to meet all their body’s needs (Bennett, Thomas and Riegel 2004).

SIGNS OF DEHYDRATIONIn the absence of a clinical definition for dehydration, the most accepted definition is the ‘rapid weight loss of greater than 3% body weight’. Other definitions state dehydration as a water and/or electrolyte imbalance, either with water depletion only or with sodium depletion with an associated loss of water (Hodgkinson, Evans and Wood 2003).

Detectable clinical and physical signs of dehydration include appearance of a dry tongue and mucous membranes, sunken eyes, poor cognition, speech difficulty, confusion, upper body muscle weakness, raised body temperature, low fluid intake, dry armpits and palms, slow capillary refill, low urine volume and usually dark or concentrated urine. These signs have the strongest correlation with dehydration. The severity of dehydration is determined by biochemical markers (Hooper et al 2013; Hodgkinson, Evans and Wood 2003).

Sequential biochemical markers have an important role in monitoring for possible dehydration and in any assessment. The relevant markers often performed as part of ‘routine’ monitoring are plasma urea/creatinine ratio and serum osmolality, sodium and tonicity (Hooper et al 2013). Other measurements including urine concentration such as specific gravity may be needed for diagnosis and management when dehydration is suspected.

At one end of the scale, mild dehydration may cause someone to feel only a little thirsty. At the other end, severe dehydration can result in death.

WHY THE OLDER PERSON IS AT RISK OF DEHYDRATIONOlder people have similar fluid requirements to those of younger adults. However, some age related changes and problems put older people at increased risk of not drinking sufficient fluid to meet their daily requirements.

Thirstsignalandappetite: The body is provided with a thirst signal to indicate when we need to drink more fluid. Most people drink sufficient water or other fluids and so infrequently feel thirsty. In older people, the thirst signal is often impaired, so they do not feel the sensation to drink (Scales 2011). As a result, older people will often refuse drinks when they are dehydrated because they do not feel thirsty. Furthermore, a diminished appetite or poor nutrition may result in the older person not eating or drinking adequately.

Socialsetting: Many of our social interactions revolve around eating and drinking. For some older people either living along or having moved into a residential care facility, their life routines have significantly changed. Opportunities to have a cup of tea with friends or family may no longer be a prompt to have a drink. In addition, some people have never developed good drinking habits and resist the offers of fluid particularly if they do not have a good thirst mechanism.

Healthproblems: A number of health problems put older people at risk of dehydration and some examples are listed below:

Dementia - the person may forget to drink or not be able to interpret the thirst sensation.

Neurologicaldisorders - such as Parkinson’s disease, stroke and Motor Neurone disease may result in the person having difficulties in swallowing or impair their ability to get fluids independently.

Incontinenceorpoorbladdercontrol– many people with bladder problems reduce their fluid intake hoping to minimise episodes of incontinence and reduce the number of trips to the toilet, especially at night.

Increasingfrailty - everyday tasks become more difficult with increased age, resulting in greater dependence on others for assistance with drinking and eating.

9 DEHYDRATION WATER FOR WELLBEING

WATER FOR WELLBEING10 WATER MYTHS AND FACTS

WATER MYTHS AND FACTS

WATER FOR WELLBEING11 WATER MYTHS AND FACTS

MYTH DRINK EIGHT GLASSES OF WATER EACH DAY

FACT There is no clear benefit from drinking this amount of water each day and the origin of this claim is not based on research evidence (Rush 2013). Of the 2 to 3 litres of water a day your body needs, about one litre is obtained from the food we eat, and your body produces another 250mL when it metabolises the food. This leaves about 1.25-1.75 litres to actually drink. This is equal to about six cups, each 250mL. More importantly, this fluid can be obtained from a number of sources, not just water.

MYTH IF YOU HAVE A BLADDER CONTROL PROBLEM, DRINKING LESS WATER HELPS

FACT People who have bladder control problems often reduce their fluid intake so they don’t need to go to the toilet as often. However, less fluid intake has the effect of concentrating the urine, which can irritate the bladder causing more frequent visits to the toilet.

MYTH OLDER PEOPLE ARE AT GREAT RISK OF OVERHYDRATION

FACT Whilst some older people are on fluid restrictions due to specific health conditions such as congestive heart failure or renal disease, the risk of dehydration is greater for the majority of older people and is far more common.

MYTH TEA AND COFFEE HAVE A DIURETIC EFFECT SO DON’T COUNT TOWARDS DAILY FLUID INTAKE

FACT There is still debate on whether caffeine, found in tea, coffee and some carbonated soft drinks have a diuretic effect. A recent review suggests that caffeine has a mild diuretic effect and may increase urine output; however, the fluid consumed in the beverage counteracts this short-term effect and contributes towards fluid intake (Benelam and Wyness 2010).

MYTH BY THE TIME YOU GET THIRSTY, YOU ARE ALREADY DEHYDRATED

FACT The body’s thirst signal sets in well before the threshold for dehydration. However, the sensitivity to this signal decreases with age, so that if an older person is thirsty, they may already be dehydrated.

MYTH IF YOUR URINE IS DARK, YOU’RE DEHYDRATED

FACT Urine colour alone does not signal dehydration. If less urine volume is also present and/or desire to urinate is less than twice a day, then dehydration is possible. Some medications, vitamins and foods are also known to alter the colour of urine.

MYTH BOTTLED WATER IS BETTER THAN TAP WATER

FACT Not necessarily. Australia has access to some of the safest, best quality tap water which adheres to guidelines set by the National Health and Medical Research Council. A Choice (2013) article found that bottled water costs almost 2000 times more than tap water, with no health benefits. If poor tasting tap water is an issue, consider using a filter cartridge to help modify taste.

MYTH DRINKING LOTS OF WATER HELPS CLEAR OUT TOXINS FROM THE BODY

FACT A key function of the kidneys is to remove waste and excess material in urine. Kidney function, namely filtration, is not enhanced by a greater water intake. Kidney filtration is reduced in severe dehydration.

MYTH DRINKING EXTRA WATER LEADS TO WEIGHT LOSS

FACT There is some evidence that water consumed before or during a meal does promote satiety or feeling ‘full’ and slightly increases energy expenditure, however, due to a lack of good-quality studies, further research is required (Muckelbauer et al 2013).

WATER FOR WELLBEING12 STRATEGIES ON HOW TO ENCOURAGE ADEQUATE FLUID INTAKE

In residential aged care, it has been estimated that a third of residents are dehydrated (Mentes and Wang 2010). In conjunction with existing practices, the following research-based strategies may be effective in increasing and maintaining adequate fluid intake among older people.

FLUID INTAKE PATTERNSOlder people should be offered drinks and encouraged to drink regularly throughout the day. Taking small sips often assists fluid absorption by the body rather than drinking large amounts at once (Schols et al 2009). Furthermore, overhydration can result from consuming very large quantities of fluid if the older person has a diminished ability to excrete water as seen in severe cardiac, liver or renal failure. (Benelam and Wyness 2010; Heneghan et al 2012).

In residential care, staff should offer or encourage the older person to drink fluid during meals, with snacks and regularly in between meals. Daily activities such as brushing teeth, taking medication, during social activities and therapy are key opportunities to encourage fluid consumption (Schols et al 2009; Godfrey et al 2012).

For people with an overactive bladder, urge incontinence or severe cognitive impairment, fluid limitations two hours before sleep and ensuring a trip to the toilet before bedtime can be considered (Stewart 2010).

SUPPORTIVE ENVIRONMENTAs people age, physical and cognitive function declines, which may result in the need for assistance to drink fluid. It is important to create a supportive environment for drinking by making older people comfortable, placing drinks within reach, pouring out their drinks, placing the drinks in their hands and using drinking aids when required. For older people that are unable to ask for a drink, regular offerings throughout the day may be a simple solution (Godfrey et al 2012).

Godfrey et al (2012) highlights the importance of making drinking a pleasurable experience by encouraging staff and relatives to sit with the older person, engage in a conversation and have a drink with the person.

TYPES OF FLUIDPreferreddrinks

Older people should be encouraged to drink water as well as being provided with their preferred drinks. This has been shown to increase fluid intake (Simmons, Alessi and Schnelle 2001). Certain drinks, such as tea and coffee, may trigger fond memories and be associated with socialising with friends and family. Godfrey et al (2012) suggests that in conjunction with a supportive environment, the presentation of appealing drinks should promote enjoyment and respect the dignity of the older person. This includes not only offering a person’s preferred drink, but also the preferred temperature of the fluid and type of drink vessel (Hooper et al 2013).

STRATEGIES ON HOW TO ENCOURAGE ADEQUATE FLUID INTAKE STRATEGIES ON HOW TO ENCOURAGE ADEQUATE FLUID INTAKE

WATER FOR WELLBEING13 STRATEGIES ON HOW TO ENCOURAGE ADEQUATE FLUID INTAKE

Caffeine

There are often claims made about the diuretic effects of caffeine, which is thought to cause a loss of fluid from the body as a result of a stimulation urine output. As mentioned, in the myths and facts section of this resource, a recent review suggests that caffeine has a mild diuretic effect and may increase urine output. However, the fluid consumed in the beverage counteracts this short-term effect (Benelam and Wyness 2010). Also, the link between high caffeine intake and urinary incontinence remains controversial as studies have found either no association or limited association (Karon 2009).

In the case of the older person who habitually drinks tea and coffee, these fluids should not be restricted, as it may lead to dehydration. However, tea and coffee should not provide the only source of fluid intake.

Alcohol

Alcohol has a diuretic effect; however water and alcohol content is variable depending on the type of alcoholic beverage consumed. A standard drink of beer will have more water and less alcohol than a standard drink of wine and even more so than in a standard drink of spirits. Without additional fluids, alcoholic drinks may cause dehydration and should be limited (Benelam and Wyness 2010; Schols et al 2009). The National Health and Medical Research Council recommends no more than two standard drinks a day for men and women.

Thickenedfluids

For older people that have swallowing difficulties (dysphagia), the use of fluid thickeners can assist with fluid intake. When using thickened fluids, care needs to be taken when preparing the correct viscosity. Fluid entering the lungs (aspiration) may result if fluids are too thin. Fluids that are too thick may cause a person to choke or deliver less water than the measured volume, increasing the risk of dehydration. Staff training in the preparation and administration of thickened fluids is recommended (Hines et al 2010).

Oralhydrationsupplements

Further research is required to determine the effectiveness of oral hydration supplements. In one study, hydration was found to have been significantly improved when an oral hydration solution was supplied to supplement fluid intake up to the client’s pre-determined total fluid goal. The study was however, not randomised or controlled and included a small number of experimental subjects (Hodgkinson, Evans and Wood 2001).

WATER FOR WELLBEING14 MONITORING HYDRATION STATUS AND FLUID INTAKE

Individuals should be screened and monitored for hydration problems. General monitoring should include any signs or symptoms of dehydration, the onset of complications, and the impact of treatments including any undesired effects of treatments. Monitoring of vital signs, general strength, function and cognition should be conducted.

If an individual is determined to be at risk of dehydration, monitoring fluid intake and urine output should be performed. This is usually only feasible or needed for short-term fluid monitoring and for people in whom acute changes in fluid balance are clinically important. Daily weighing using accurate scales is another method of monitoring fluid balance (Scales 2011). This can be followed with further laboratory assessments for dehydration to confirm a diagnosis (Ruxton 2012).

A dehydration risk appraisal checklist (DRAC) can also be used to identify individuals at risk of dehydration (see appendix for checklist).

URINE COLOURUrine colour has been promoted as an effective method for monitoring fluid intake. Urine that is plentiful, odourless and pale in colour (pale straw) generally indicates that a person is well hydrated. Dark (like apple juice), strong-smelling urine in small amounts could be a sign of dehydration.

However, there are medications, vitamins and foods which change urine colour and urine passed when dehydrated can still be pale (e.g. urine passed with high outputs of sugar is usually pale). Also, incontinence pads which are commonly used in aged care makes it difficult to assess urine colour. Decisions about fluid status based just on urine colour may be incorrect for several reasons but the interpretation of colour change in urine may be a useful alert to a need for more fluid intake or to investigate further.

The best results are obtained in older adults with adequate renal function once the effect of discolouration by food and medications has been ruled out. This method is most effective when the average urine colour baseline is calculated over several days (Mentes, Wakefield and Culp 2006).

MONITORING HYDRATION STATUS AND FLUID INTAKE

ThefollowingarerecommendationsforimprovingadequatefluidintakeamongtheolderpersonforuseinresidentialagedcareandHACC:

1 Frail older people should drink at least 1500mL of fluid a day, unless advised otherwise by their doctor

2 Provide or encourage small amounts of fluid to be taken consistently throughout the day

3 Offer fluids at 1.5 hourly intervals to bedridden residents through the day

4 Offer preferred fluids

5 Caffeinated beverages (e.g. tea and coffee) are a source of fluid and can be counted towards the daily fluid intake goal. Tea and coffee should not be the only source of fluid intake

6 Alcoholic beverages should be limited to no more than two standards drinks a day for men and women

7 Identify and monitor at risk individuals; fully dependent for dehydration and semi-dependent for adequate fluid intake

8 Monitor fluid intake and or output

9 Educate carers and older people on the volumes of containers to serve fluids

Promote fluid intake at the beginning and end of organised activities and also during the activity

RECOMMENDATIONS FOR HYDRATION

10

WATER FOR WELLBEING15 RECOMMENDATIONS FOR HYDRATION

WATER FOR WELLBEING16 REFERENCES

Armstrong. L., J. Soto, F. Hacker, D. Casa, S. Ka-vouiras, and C. Maresh. 1998. Urinary indices during dehydration, exercise, and rehydration. International Journal of Sport & Nutrition 8: 345-55.

Benelam, B., and L. Wyness. 2010. Hydration and health: a review. British Nutrition Foundation Nutrition Bulletin 35: 3-25.

Bennett, J., V. Thomas, and B. Riegel. 2004. Unrecognized chronic dehydration in older adults: examining prevalence rates and risk factors. Journal of Gerontological Nursing 30(11): 22-8.

Choice. 2013. The cost of bottled water. http://www.choice.com.au/reviews-and-tests/food-and-health/food-and-drink/beverages/bottled-water.aspx (accessed January 31, 2014).

Godfrey, H., J. Cloete, E. Dymond, and A.Long. 2012. An exploration of hydration care of older people: a qualitative study. International Journal of Nursing Studies 49: 1200-11.

Gray, M., and M. Krissovich. 2003. Does fluid intake influence the risk of urinary incontinence, urinary tract infection, and bladder cancer? Journal of ostomy and continence nursing 30: 726-31.

Heneghan, C., P. Gill, B. O’Neill, D. Lasserson, M. Thake, M. Thompson, and J. Howick. 2012. Myth-busting sports and exercise products. British Medical Journal doi: 10.1136/bmj.e4848.

Hines, S., J. McCrow, J. Abbey, and S. Gledhill. 2010. Thickened fluids for people with dementia in residential aged care facilities. International Journal of Evidence Based Healthcare 8: 252-55.

Hodgkinson, B., D. Evans, and J. Wood. 2001. Maintaining oral hydration in older people. The Joanna Briggs Institute for Evidence Based Nursing and Midwifery 5(1): 1-6.

Hodgkinson, B., D. Evans, and J. Wood. 2003. Maintaining oral hydration in older adults, a systematic review. International Journal of Nursing 9 (3): S19-28.

Hooper, L., D. Bunn, F. Jimoh, and S. Fairweather-Tait. 2013. Water-loss dehydration and aging. Mechanisms of Ageing and Development http://dx.doi.org/10.1016/j.mad.2013.11.009

Karon, S. 2009. Conservative management of continence in women over the age of 65 years living in the community: a review. Australia and New Zealand Continence Journal 15 (2): 34-44.

Little, M. 2012. Nutrition and skin ulcers. Current Opinion in Clinical Nutrition and Metabolic Care 16:39-49.

Lu, C., A. Diedrich, C, Tng, S. Parajape, P. Harris, D. Byrne, J, Jordan, and D. Robertson. 2003. Water ingestion as a prophylaxis against synocopy. Circulation 108: 2660-5.

Mentes, J. 2006. A typology of oral hydration: problems exhibited by frail nursing home residents. Journal of Gerontological Nursing 32 (1): 13-27.

Mentes, J. 2006. Oral hydration in older adults, greater awareness is needed in preventing, recognizing, and treating dehydration. American Journal of Nursing 106 (6): 40-9.

Mentes, J., B. Wakefield, and K. Culp. 2006. Use of urine colour chart to monitor hydration status in nursing home residents. Biological Research for Nursing 7(3): 197-203.

REFERENCES

WATER FOR WELLBEING17 REFERENCES

Mentes, J., and J. Wang. 2010. Measuring risk for dehydration in nursing home residents. Research in Gerontological Nursing 4 (2): 148-56.

Muckelbauer, R., G. Sarganas, A. Gruneis, and J. Muller-Nordhorn. 2013. Association between water consumption and body weight outcomes: a systematic review. American Journal of Clinical Nutrition 98: 282-99.

Popkin, B., K. D’Anci, and I. Rosenberg. 2010. Water, hydration, and health. Nutrition Reviews 68 (8): 439-58.

Rogers, P., A. Kainth, and H. Smit. 2001. A drink of water can improve or impair mental performance depending on small differences in thirst. Appetite 36: 57-9.

Rush, E. 2013. Water: neglected, unappreciated and under researched. European Journal of Clinical Nutrition doi:10.1038/ejcn.2013.11

Ruxton, C. 2012. Promoting and maintaining healthy hydration in patients. Nursing Standard 26(31): 50-6.

Scales, K. 2011. Use of hypodermoclysis to manage dehydration. Nursing Older People 23 (5): 16-22.

Schols, J., C. De Groot, T. Van Der Cammen, and M. Olde Rikkert. 2009. Preventing and treating dehydration in the elderly during periods of illness and warm weather. The Journal of Nutrition, Health & Ageing 13 (2): 150-6.

Shepherd, A. 2011. Measuring and managing fluid balance. Nursing Times 107 (28): 12-6.

Shimizu, M., K. Kinoshita, K. Hattori, Y. Ota, T. Kanai, H. Kobayashi, and Y. Tokuda. 2012. Physical signs of dehydration in the elderly. International Medicine 51: 1207-10.

Simmons, S., A. Alessi, and J. Schnelle. 2001. An intervention to increase fluid intake in nursing home residents: prompting and preference compliance. The Journal of the American Geriatrics Society 49(7): 926-33.

Stewart, E. 2010. Treating urinary incontinence in older women. British Journal of Community Nursing 15(11): 526-32.

Tortora, G., and B. Derrickson. 2010. Introduction to the human body: the essentials of anatomy and physiology. 8th ed. New York: John Wiley & Sons.

Townsend, M., Y. Jura, G. Curhan, N. Resnick, and F. Grodstein. 2011. Fluid intake and risk of stress, urgency, and mixed urinary incontinence. American Journal of Obstetrics & Gynecology 205 (1): 1-10.

Tzeng. H, and C. Yin. 2012. Frequently observed risk factors for fall-related injuries and effective preventive interventions. Journal of Nursing Care Quality 28(2): 130-8.

Whitehead, E. 2009. NVQ explained, part 9: managing continence issues. Nursing & Residential Care 11 (5): 224-8.

Wilson, M., and J. Morley. 2003. Impaired cognitive function and mental performance in mild dehydration. European Journal of Clinical Nutrition 57 (2): S24-9.

WATER FOR WELLBEING18 APPENDIX

APPENDIX

The following is a brief summary of the resources to be found on the CD-ROM which is included in the kit. These resources are available in pdf format. Note some of these resources are only available electronically on the CD and not included in the printed booklet.

You will need Adobe Acrobat Reader installed in your computer to download and view these files. This program can be obtained free at the following web address: www.adobe.com.

Standard2.10NutritionandHydrationRecommendationsforHydration

Category:EducationtoolsforstaffandolderpeopleWater for wellbeing: a guide tofluid intake

A brochure for older people andcarers, explaining the benefits ofdrinking enough fluids and a guide to how much and what to drink

Fluids and the older person:factsheet

A factsheet for carers of older people explaining the benefits of and tips for encouraging adequate fluid intake

Water for wellbeing: urinary tract infections

A brochure for older people andcarers, explaining the signs andsymptoms of UTIs and their prevention

Practical tips for encouraging water consumption

A factsheet for carers with more tips to encourage older people to drink more water

Frequently asked questions (FAQs)

FAQs for carers

Hydration awareness quiz for staff

Multiple choice questions for staffprofessional development

Water for Wellbeing: a guide to fluid intake


VCRC

Water and your bodyWater is vital for your body’s health. Almost every function in the body requires water:• Breathing• Digestionandabsorption• Wasteremoval• Temperaturecontrol

• Bloodcirculation

Watermakesupabout60%ofthebodywhichhasnostoragefacilities.Freshsuppliesofwaterarerequiredeachday.

Health benefits of drinking wellDrinking well helps to:

• Reducetheeffectsofoveractivebladder,suchasfre-quencyandurgencytopassurine.Restrictingyourfluidscanirritatethebladderfurtherbyconcentratingtheurine

• PreventUTIs

• Preventconstipation

• Maintainbloodpressure

• Keepyourmindworkingwellbyimprovingconcentration,memoryandalertness

• Hydratetheskin,whichinturnmakesapersonlesspronetodamagefromknocksandbumps

• Preventfalls

• Keepthemouthmoistandhealthy

Ways fluid is lost from the bodyOn average we lose around 2.5 litres of fluid each day. Aninactiveolderpersonmaylosecloserto2litresoffluidperday.

Exercisingandhotweatherincreasestheamountoffluidslost.Themoreactiveyouarethemoreyouneedtoincreaseyourfluidintake.

Rememberitsalsoimportanttomaintainyourfluidintakeinthewintermonths.

How much fluid is enough?Wemustreplacetheamountoffluidlostorwewillendupdehydrated.

Foodprovidesabout1litreoffluidreplacement.Mostfruitandvegetablesare70-80percentwater.Mostfoodssuchasicecream,custard,soups,yoghurtandjelliesaremainlywater.Evenfoodswethinkofasdrysuchasbread,haveagoodpro-portionofwater.

But we still need to drink an additional 1500mL of fluid to match the fluid loss from day to day living, unless advised oth-erwise by your doctor.

For further information contact (03) 9816 8266 1300 220 871 [email protected] www.continencevictoria.org.au©ContinenceFoundationofAustraliaVictoriaBranchInc.SupportedbyfundingfromtheCommonwealthandVictorianGovernments


VCRC Water for Wellbeing: fluids and the older person

Why are fluids important?

How much is enough?

• Mostofusknowthatweshoulddrinkatleast1500mLoffluideachday.Manyfrailolderpeoplearenotdrinkingenoughfluidtomaintainadequatehydrationandmeettheirdailybodilyneeds.

• Someolderpeoplemaybeonfluidrestrictionsduetospecifichealthconditions.Itisadvisedtocheckwiththeirdoctor,whocanestablishadailyfluidgoalfortheindividual.

Fluids – the good and the bad

• Fluidscomeinmanyforms;water,icypoles,fruitjuice,milk,tea,coffeeandcordial.Manyfoodsaremainlyfluids(custard,jelly,icecream,yoghurt,fruitandsoup)andtheseallcontributetotherequireddailyintake.

• Teaandcoffeeareagoodsourceoffluidbutbecauseitcontainscaffeine,itshouldnotbetheonlyfluidapersondrinks.

• Alcoholshouldbelimitedasithasadiureticeffectthatcausesexcessfluidlossfromthebody.Extrawaterisrequiredtoreplacethefluidlosscausedbyalcoholconsumption.

OUR BODIES ARE APPROX

60% FLUID

• Fluidisourtransportsysteminthebody,takingnutrientstothecellsandremovingwaste

• Itsoftensbowelactions,makingthemeasiertopass

• Fluidshelptomaintainbodytemperature

• Eachdaywelosefluidthroughbreathing,sweating,urineproductionandinbowelmotions

Some symptoms of mild dehydration are:• Poorconcentration

• Irritability

• Headaches

• Fatigue

• Increasedconfusion

• Faints&falls

For further information contact (03) 9816 8266 | 1300 220 871 [email protected] | www.continencevictoria.org.au©ContinenceFoundationofAustraliaVictoriaBranchInc.

The risk of developing a urinary tract infection (UTI) increases as we get older. Women in particular are more prone to recurrent UTIs.

Urinary tract infections:• Affect the bladder and/or kidneys

• Risk increases with age

• Are more common in middle aged and older women

Common signs and symptoms:• A frequent urge to pass urine

• Difficulty in passing urine

• A burning sensation when passing urine

• Urine may be cloudy or have a strong smell

• Lower back or abdominal pain are sometimes experienced

• Behaviour changes

Why the older person is at risk?Normal age related changes lower body defence mechanisms

• Poor fluid intake

• Constipation

• Reduced mobility

• Incontinence

• Incontinence aides, especially catheters

Costs & carer burden associated with UTIsThe costs of UTIs are significant for older people and their carers. Costs include:

• Poor health outcomes for the older person

• Increased carer workload

• Increased treatment costs

• Increased care costs

UrinaryTract Infections


VCRCFor further information contact (03) 9816 8266 1300 220 871 [email protected] www.continencevictoria.org.au© Continence Foundation of Australia Victoria Branch Inc. Supported by funding from the Commonwealth and Victorian Governments

Practical tips for encouraging water

consumption

1 Start by encouraging your team to develop a policy on how residents will receive adequate hydration. Refer to standard 2.10 Nutrition and hydration.

2 A positive approach often helps to encourage older people to drink more fluids. For example, phrases such as ‘Here is some nice cool refreshing water for you’ is more productive than ‘Do you want something to drink?’

3 An ideal time to offer water is when giving older people their medications.

4 Always provide a glass of water alongside coffee, tea or alcohol.

5 Older people often worry about increased toilet visits overnight. To avoid this problem, distribute 1500mL fluids evenly throughout the day to reduce the number of late evening drinks.

6 Older people can lose their thirst response and taste sensation. Never assume that they know when to drink.

7 Where possible inform family and friends about the importance of promoting hydration.

8 For day trips and for use in outside areas, providing a personal water bottle can help. These are easy to carry, to clean and to refill, and can be marked clearly with the person’s name.

9 Hot water with a piece of fruit such as lemon, lime or orange, can appeal to those who want a hot drink.

10 Introduce older people to a variety of herbal teas as an alternative to plain water.

11 As the weather gets warmer encourage and remind older people to drink more. Perspiration increases in warmer weather. Extra fluids may need to be offered overnight.

12 Offer and encourage fluids during a meal times. Make sure that older people who are less able are assisted to drink.

13 Use a symbol such as a water drop near those who are at specific risk and need their water intake monitored. Make sure staff are aware of the symbol and its meaning.


VCRCFor further information contact (03) 9816 8266 1300 220 871 [email protected] www.continencevictoria.org.au© Continence Foundation of Australia Victoria Branch Inc. Supported by funding from the Commonwealth and Victorian Governments

Frequently asked questions (FAQs)


VCRC

Q1. How can I get an older person to enjoy and ask for water?

• Presentation of tap water is important to help increase consumption.

• Assist the older person to make improved healthy choices by helping them to understand the benefits (see the Practical tips for encouraging water consumption fact sheet).

Q2. How should I offer tap water to make it taste as good as possible?

• Taste tests have shown that tap water is enjoyed when it is provided fresh and cool (not too cold and not warm).

• Improve the taste of plain water by adding a flavoured ice cube, fresh mint or a slice of fruit. This lifts the visual as well as taste sensation.

• Tap water provided from water coolers becomes a feature, and allows water to be offered chilled or at room temperature.

• If offering cordials, make sure they are well diluted, fortified (eg with vitamin C) and sugar-free.

Q3. What can I do if an older person insists on drinking mostly hot drinks?

• That’s fine as long as they are drinking plenty of appropriate fluids.

• Promoting hot water with pieces of fruit in it works well.

• Try and avoid strong caffeinated drinks and offer caffeine-free as an alternative.

Q4. Is tap water safe to drink?• Yes. The mains tap water supply in most urban and

regional areas is safe to drink and of high quality.

• Always make sure that the tap water you are providing is fresh from the mains and not from stored water tanks, where possible.

• If in doubt about the water quality in your building, always check with your local water company first, particularly in drought affected areas.

Q5. Do I need to filter or treat tap water be-fore I offer it to drink?

• No. The tap water is carefully monitored and tested and is supplied ready to drink straight from the tap.

• Sometimes filters will polish the taste slightly, but the same effect can normally be achieved by leaving the water to stand.

• Adding a little ice or chilling the water in the fridge will help take away any chlorine taste.

Q6. How much water should an older person drink?

• Guidelines for adequate fluid intake among the frail older person suggest a minimum of 1500 mL of fluid per day.

• What we do know is that most people, especially older people, drink nowhere near that amount, and mild dehydration is very common.

• It is vital to encourage older people (and staff) to drink more.

For further information contact (03) 9816 8266 | 1300 220 871 [email protected] | www.continencevictoria.org.au© Continence Foundation of Australia Victoria Branch Inc.

1. What is the chemical name for drinking water?

H20

C3PO

He3

2. How much minimum fluid should the frailolder person drink each day for good health?

2 litres

1500mL

2.5 litres

3. Approximately how much of your body is made up of water?

60%

40%

15%

4. How long can you live without water?

About one week

About one month

About one year

5. Which drink would be best to drink to protect your teeth and gums?

Fizzy cola

Coffee

Water

6. How should you drink your daily water intake?

All at once

Regular sips

Big mouthfuls

7. How much water does simply breathing in and out use up each day?

A pint (600mL)

A glass (250mL)

A bathful

8. How much water on average is removed from the body daily as urine from the bladder?

250mL

400–500mL

1 litre

1.5 litres

Photocopy this sheet and tick off your answers. Correct answers are given over the page.


VCRC Hydration awarenessquiz for staff

For further information contact (03) 9816 8266 | 1300 220 871 [email protected] | www.continencevictoria.org.au© Continence Foundation of Australia Victoria Branch Inc. Supported by funding from the Commonwealth and Victorian Governments

WATER FOR WELLBEING19 APPENDIX

Poster Awareness raising poster

Category:Careprovisiontoolsforstaff

Management strategies for different types of fluid intake problems

Chart for carers outlining the different types of fluid intake problems of older people and suggested management strategies to use in addressing these

Am I hydrated? Urine Colour Chart

Chart for carers and older people to use in monitoring hydration status

My Daily Fluid Intake Record Chart for HACC carers and clients to use to monitor fluid intake

Dehydration risk appraisal checklist

Checklist for residential care nursing staff/carers to identify residents at risk


VCRC

Are you drinking enough water?

Make water your first choice

Keep your system flushing well,drink at least 1500mL of fluid a day

Call 1300 220 871 for further information or visit www.continencevictoria.org.au

Management strategies for different types of fluid intake problemsVICTORIAN CONTINENCE RESOURCE CENTRE

VCRC

Those who are physically incapable of accessing or safely consuming fluids related to physical frailty or

difficulty swallowing

Functionally capable of accessing and consuming fluids but may not know what is adequate intake or

may forget to drink

CAN DRINK CAN’T DRINK WON’T DRINK

Those who are capable of consuming fluids safely but who do not because

of concerns about being able to reach the toilet with or without

assistance or relate they have never consumed many fluids

Source: Mentes, J. 2006. A typology of oral hydration: problems exhibited by frail nursing home residents. Journal of Gerontological Nursing 32 (1): 13-27

• Educate; how much

• Use measuring cup

• Provide preferred beverages

INDepeNDeNT FORgeTs

• Frequent offers

• Fluid during activities

• Tea time/happy hours

• Beverage cart

sWAllOWINg DIFFICulTIes

• Swallowing exercises

• Foods rich in fluid, smoothies

• Oral care

• Educate family to help

physICAlly DepeNDeNT

• Sports cup with straw

• Physical aids to assist with drinking

FeARs INCONTINeNCe

• Educate about maintaining fluid intake

• Pelvic floor exercises, urge inhibition

• Medication as a last resort

sIppeR

• Sports cup with straw

• Physical aids to assist with drinking


Am I hydrated? Urine Colour Chart


VCRC

Use this simple urine colour chart to assess if you are drinking enough fluids throughout the day to stay hydrated. Match the colour of your urine sample to a colour on the chart.

1 to 3 = HydrAtedThis is ideal

4 to 6 = MIldly deHydrAtedStart to increase your fluids

7 or 8 = deHydrAtedDrink more fluid

1

2

3

4

5

6

7

8

Note: Use of a urine colour chart is suggested for people with adequate renal function and not by people who wear incontinence pads.

Best results are obtained when the average urine colour baseline is calculated over several days.

The colours you see on this chart should only be used as a guide.

Reference: Armstrong. L., J. Soto, F. Hacker, D. Casa, S. Kavouiras, and C. Maresh. 1998. Urinary indices during dehydration, exercise, and rehydration. International Journal of Sport & Nutrition 8: 345-55.

Urine that is plentiful, odourless and pale in colour (pale straw) generally indicates that a person is well hydrated.

Dark, strong-smelling urine, (like the colour of apple juice), in small amounts could be a sign of dehydration.

Certain foods, medications and vitamin supplements may cause the colour of urine to change even though you are hydrated.


My Daily Fluidintake Record


VCRC

For further information contact (03) 9816 8266 | 1300 220 871 [email protected] | www.continencevictoria.org.au

DRink Most

DRink in MoDeRation

DRink less

Tick a drink below when each drink is finished. Try to have the most number of ticks in the ‘drink most’ category.

Make water your first choice. Tea, coffee, cordial, milk and fruit juice are good sources of fluid too, but should not be the only drinks you have. Alcohol and soft drinks should be limited.

The recommended minimum daily fluid intake for older people is 1500mL (6 cups) per day.(Unless advised by the doctor)

aRe you DRinking enough?

© Continence Foundation of Australia Victoria Branch Inc. Supported by funding from the Commonwealth and Victorian Governments

Dehydration riskappraisal checklist

A dehydration risk appraisal checklist (DRAC) can be used to identify individuals at risk of dehydration. The total number of risk factors should be totalled. The higher the number of risk factors checked, the higher the risk of dehydration.

DehyDration risk appraisal checklist

significant health conditions checklist

MMSE * score <24 (indicating cognitive impairment)

Urinary incontinence

Dementia diagnosis

GDS * score >6 (indicating depression)

Semi-dependent in ADLs *

Repeated infections

History of dehydration

intake behaviours checklist

Abnormal body mass index

Can drink independently but forgets

Has difficulty swallowing

Requires assistance to drink

Poor eater

Medications checklist

Laxatives agents

Psychotropic agents

Diuretic agents

*ADLs = activities of daily living; GDS = Geriatric Depression Scale; MMSE = Mini-Mental State Examination

Source: Mentes,J., and J.Wang.2010. Measuring risk for dehydration in nursing home residents. Research in Gerontological Nursing 4 (2): 148-56.



VCRC

P: (03) 9816 8266F: (03) 9853 9727Advice Line: 1300 220 871E: [email protected]

Continence Foundation of Australia Victorian Branch

water for wellbeing · (tortora and derrickson 2010). water is critical to many bodily functions -...

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