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Over 160,000 Australians receive permanent residential aged care services 1 and the vast majority of these are either physically or cognitively impaired. The illnesses that lead to admission into residential care may in turn make it more difÞcult for care staff to maintain the residentsÕ nutrition and hydration. There has been very public community concern about the quality of residential care, and both poor nutrition and inadequate hydration have been appropriately cited as indicators of inadequate care 2-4. These clinical guidelines have been developed as a practical tool for residential care staff to better manage one aspect of quality care Ð hydration Ð and to better prevent and manage dehydration in this setting. DeÞnitionDehydration is a reduction in total body water volume a nd may be deÞned as signiÞcant when over 3% of body weight is lost. However, it is often difÞcult to determine precisely how much weight has been lost and whether it is all due to water loss. Dehydration is usually regarded as present when it is accompanied by changes in biochemical indices and by clinical features (see below, under diagnosis). Prevalence of dehydration in institutional care Studies within nursing homes have found that dehy dration is frequent. One prospective study found dehydration events occurred in 31% of residents over 6 months 5. and another found that 98% of residents consumed less than the daily recommended ßuid intake6. In another study some 91 of 339 elderly nursing home residents who became ill had biochemical features of dehydration 7.Many hospital admissions of nursing home residents are associated with dehydration and the electrolyte disturbances that may indicate dehydration. In one study, 34% of nursing home patients admitted to hospital were diagnosed with dehydration 8. Another study found 84% of hypernatraemic patients developed this during adm ission to hospital Ð only 16% were hypernatraemic on admission9.Consequences of dehydrationDehydration is associated with increased hospitalisation and mor tality. It may not be easy to distinguish between poor outcomes due to an underlying illness and poor outcomes from dehydration itself. In one study of 130 nursing home residents there were 48 febrile episodes over a 4 month period and 14 febrile residents had biochemical markers of dehydration. Of the 5 febrile residents who died, all had markers of dehydration 10. This unintended dehydration and associated increased mortality should be distinguished from the dehydration that frequently accompanies terminal illnesses such as cancer and renal failure 11.Risk factors for dehydrationThe greatest risk factor for dehydration is poor oral intake. In the study of 48 febrile episodes in nursing home residents, 11 patients were noted by staff to have poor oral intake and nine of these (82%) developed biochemical markers of dehydration 10. In a study of hospitalized patients, 86% of patients who developed hypernatraemia in hospital lacked free access to water 9.

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Other signiÞcant risk factors for dehydration in a study of 339 elderly residents who became ill included female gender, age over 85, four or more chronic conditions, use of more than four medications and being bedridden 7. Among those who were most severely dehydrated, inability to feed oneself and impaired functional status were additional risk factors. In another study, diuretic use was a risk factor for electrolyte disturbances in elderly people requiring hospitalization 12. Diuretic use is a recognised risk factor in the genesis of renal impairment and electrolyte disturbances, especially in older people 13, and is likely to increase the risk of dehydration in nursing home residents. The availability of appropriately skilled staff to assist residents is also a factor that contributes to the risk of dehydration. Dr Kayser-JonesÕ research in the USA has repeatedly revealed that inadequate stafÞng, lack of assessment and disregard for personal and cultural preferences contribute to inadequate ßuid intake and dehydration in residential care 3,6,14. These Þndings have been replicated by others Ð in a recent study weight loss and dehydration were 17% less likely in facilities that provided residents with at least 3 hours of nursing assistant care daily compared with those providing less than 3 hours daily 15.Risk factors for dehydration are summarised in Table One and should alert care staff to being more attentive to ßuid intake and the signs of dehydration.Table One RISK FACTORS FOR DEHYDRATION POOR ORAL INTAKE Inability to feed independently Refusing oral intake Poor access to ßuids Oro-pharyngeal disease INCREASED FLUID LOSS Febrile Illness Diarrhoea and vomiting Diuretics Illnesses increasing urine output unstable diabetes hypercalcaemia hypokalaemiaOTHER FACTORS Female gender Older age Greater number of medications Impaired functional status Dementia and other confusional states Greater number of illnesses/chronic conditions INADEQUATE STAFFING Inadequate staff training / awareness of hydration Older people have a reduced thirst in response to ßuid deprivation 16 and their hormonal response to dehydration (secretion of anti-diuretic hormone) may also be impaired 17. These changes may be even more pronounced in residents with AlzheimerÕs disease18, a common condition in residential care. These factors both make older people more prone to dehydration and also indicate that thirst cannot be relied upon as an indicator of dehydration.

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Normal ßuid intakeFluid intake must replace measurable losses (urine, faeces and occasionally others such as drain tubes) and insensible (not easily measured) losses from respiration and through the skin. The recommended minimum total ßuid intake is 1500Ð2000 mL, (equivalent to 6Ð8 250 mL cups) a day. This comes from all sources including soups and beverages. A formula used to calculate ßuid requirements for older people is: Table Two shows these recommended ßuid requirements. Table Two Patient Weight (kg) Fluid requirement (litres/day) Other formulae for recommended ßuid intake are less accurate and may underestimate ßuid requirements, especially in underweight residents 19. These include 30 mL/kg body weight and 1 mL/kcal energy consumed.Presentation of dehydration Signs of dehydration include dry mucous membranes, reduced tissue turgor (elasticity), reduced sweating, sunken eyes, tachycardia, low blood pressure and postural blood pressure drop, altered consciousness including confusion, increasing functional impairment, weakness, constipation, reduced urine output and more concentrated (darker) urine. Unfortunately many of these signs are quite subjective, with no deÞned ÒnormalÓ ranges, and thus poor positive and negative predictive values for the diagnosis of dehydration. Some of these signs can be present in other conditions Ð for instance, low blood pressure can be due to over treatment with medications that lower blood pressure, in cardiac failure and when there is autonomic neuropathy. Indeed, over-reliance on low blood pressure as a sign may lead to over diagnosis of dehydration. In a study of 102 consecutive medical admissions in people older than 65 with a diagnostic coding of dehydration (16% admitted from nursing homes), only 17% had biochemically conÞrmed dehydration (serum osmolarity above 295 mOsmol) suggesting over-diagnosis by physicians, probably due to over-reliance on physical signs or other less accurate biochemical indices20. Another study of 150 elderly patients and residents with dehydration (deÞned as hypernatraemia) found that most of the classical signs of dehydration were irregularly present 21. There were four signs that were signiÞcantly and independently associated with hypernatraemia Ð abnormal subclavicular and thigh skin turgor, dry oral mucosa and recent changes in consciousness. 30354045505560657075808590951001051.

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22 Ð tissue or blotting paper is placed in a recent darkening of urine as a useful sign, as it correlates well with serum osmolarity 23 but may be difÞcult to monitor in incontinent residents 24.The more useful clinical signs of dehydration are shown in Table Three. Table Three More useful clinical signs of dehydration Reduced skin turgor Dry oral mucosa Recent change in consciousness Darker urineDiagnostic tests for dehydration circumstances. Other tests that are used include an elevated blood urea nitrogen to creatinine ratio and an elevated serum sodium although these tests are more liable to be abnormal for reasons other than dehydration. All three values are stable in non-ill residents of nursing homes, so a change from baseline values can be relied on to suggest dehydration has occurred 25. A single elevated value in a resident in the absence of clinical features of dehydration is not diagnostic of dehydration Ð some elderly people appear to have an elevated central osmolarity setting 25 also be a useful sign but has not been carefully evaluated. These biochemical signs of dehydration are shown in Table Four Table Four Biochemical signs of dehydration*SignRaised serum osmolalityRaised serum sodiumRaised blood urea/creatinine ratio * Only diagnostic in the presence of clinical signs of dehydration Value Above 295 mOsmolAbove 145 mmol/LAbove 50 (urea in mmol/L and creatinine also in mmol/L)

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Prevention of dehydration in residential care GeneralStaff in residential care facilities need to be trained to recognise the importance of maintaining adequate hydration, normal ßuid requirements and how to monitor intake. They should also be able to identify situations where a resident is at greater risk of dehydration, clinical features of dehydration and strategies to increase ßuid intake. There needs to be adequate stafÞng levels to attend to hydration needs, but volunteers and visitors should also be involved in this task. A wide range of strategies to maintain and increase ßuid intake have been utilized. Some have been subjected to research studies Ð including regular rounds with a hydration cart 26, using volunteers and providing a Òhappy hourÓ 27 and prompting residents to drink and providing preferred ßuids 28. Many other approaches are utilized and the key to success appears to be tailoring a program to suit local conditions. Some of the studies are presented in Appendices Two and Three. Table Five Strategies to maintain / increase ßuid intake Regularly offer ßuids Ð e.g. every 1 ! hours by dayOffer ßuids at speciÞc routine events before / after showering or washingafter toileting before / after physiotherapy or other activity program medication rounds Regular hydration cart rounds Offer residents their preferred drinks Prompt residents to drink at meal times Have a social hour where ßuids are offered Keep a ßuid intake chart especially for at risk residents Use a symbol such as a drop of water on trays of residents who need to drink more, to prompt staff. Measure urine speciÞc gravity monthly Measure osmolality, sodium and/or blood urea/creatinine ratio when bloods are being taken for other reasons. Identify at risk residents and pay more attention to them Ð e.g. confused, refusing ßuids, febrile, on diuretics (see Table One).

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Appendix one(Italics indicates suggestions to increase daily intake) Breakfast Milk on cereal Ð 200 mL Cup of tea Ð 200 mLJuice 100 mLAfter showerWater offered Ð 100 mL Morning tea Cup of tea Ð 200 mLLunchCordial drink Ð 150 mL Afternoon tea Cup of coffee Ð 200 mL Water Ð 50 mL encouraged when tray cup cleared away (Hydralyte Ice Block offered on hot days Ð 62.5 mL) Extra ßuid offering 100 mL water/other beverage given by a staff member/ visitorDinnerSoup Ð 150 mLMilk drink Ð (e.g. plain, ßavoured, supplement) Ð 200 mL BedtimeWater or Hydralyte Ð 50 mL offered prior to sleep Medication rounds 100 mL Hydralyte with one medication round, 100 mL Total 1250 mL per day Ð inadequate Total 2000 mL Ð adequate Appendix twoHydration Case Study #1Joan is a 45 kg lady with mild dementia and urinary incontinence. She suffers with frequent urinary tract infections and is slightly underweight having lost 5 kg in the last 12 months. She feeds herself, however requires prompting and encouragement. A ßuid intake chart shows Joan only consumed around 1 litre of ßuid per day. How can we improve JoanÕs nutritional status focusing on her ßuid intake?Plan: We would like Joan to maintain or gain some body weight, reduce the frequency of her urinary tract infections and have more enthusiasm about her eating, i.e. require less prompting. Joan may require prompting because she may be feeling lethargic due to dehydration and confusion that can be caused due to UTIs.A urine speciÞc gravity test or simple observation of urine colour could be done if a few drops of urine can be collected which we would predict will show dehydration due to the low ßuid intake.Using the above formula JoanÕs ßuid minimum requirement is 1875 mL per day. Below shows some of the opportunities where Joan can consume ßuid and easily achieve her ßuid requirement. Many more opportunities could be available. Therefore trial and error should be used to see what suits the resident best. Proposed ßuid intake for Joan Breakfast Cereal Ð milk 150 mL Juice (cranberry) Ð 100 mLCup of Tea Ð 200 mL Pre/post shower Morning tea High energy supplement milk base drink Ð 200 mL LunchCordial drink Ð 150 mL Custard (100 mL) and pudding Afternoon tea Cup of Tea Ð 150 mL Milk Shake Ð 150 mLDinner/Tea time Soup Ð 200 mLSupper time60 mL HydralyteCup of tea Ð 100 mLMedication rounds Lunch Ð 100 mL Hydralyte Total 2310 mL

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Appendix three Hydration Case Study #2Ted is a healthy weight gentleman at 80 kg. He has developed a swallowing problem after a recent stroke and is now having semi thickened ßuids and soft foods. He dislikes the semi thickened drinks and has recently been drinking very little. His urine is very dark and with a strong odour. He is feeling quite lethargic and has a dry mouth making it difÞcult to swallow his food.Plan: The semi thickened drinks can be difÞcult for residents to get used to. Small volumes frequently are probably best to try. Ted may be lethargic due to dehydration, his dry mouth, dark and odorous urine are also symptoms indicating insufÞcient ßuid intake. A ßavoured drink may need to be given rather than plain water if Ted is not enjoying the thickened drinks. TedÕs estimated ßuid requirement using the formula would be 2400 mLProposed ßuid intake for Ted TedÕs drinks will all be thickened Breakfast Cereal Ð milk 200 mL Juice Ð 100 mLCup of tea Ð 200 mLPre/post shower Morning Tea Cup of Tea 150 mL Pre/post physiotherapy sessions sessions therefore losing some electrolytes and he may enjoy a ßavoured drink encouraging consumption) LunchCordial drink Ð 150 mL Custard (100 mL) and pudding Afternoon tea Cup of tea Ð 150 mLDinner/Tea time Soup Ð 200 mLSupper timeWarm milk drink 200 mL Medication rounds Total 2400 mL Notes

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References 1. 2. Thompson M. Fatal neglect. In possibly thousands of cases, nursing-home residents are dying from lack of food and water and the most basic level of hygiene. Time 1997; 150: 34-8. 3. Kayser-Jones J. Malnutrition, dehydration and starvation in the midst of plenty: the political impact of qualitative inquiry. Qualitative Health Research 2002; 12: 1391-405. 4. Sullivan RJ. Fluid intake and hydration: critical indicators of nursing home quality. North Carolina Med J 2005; 66: 296-9. 5. Mentes JC. A typology of oral hydration problems exhibited by frail nursing home residents. J Geront Nurs 2006; 32: 13-9. 6. Kayser-Jones J, Schell ES, Porter C, Barbaccia JC, Shaw H. Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision. J Am Geriatr Soc 1999; 47: 1187-94. 7. Lavizzo-Mourey R, Johnson J, Stolley P. Risk factors for dehydration among elderly nursing home residents. J Am Geriatr Soc 1988; 36: 213-8. 8. Hodgkinson B, Evans E, Wood J. Maintaining oral hydration in older people. The Joanna Briggs Institute for Evidence based Nursing and Midwifery. Adelaide 2001. 9. Palevsky PM, Bhagrath R, Greenberg A. Hypernatraemia in hospitalised patients. Ann Int Med 1996; 124: 197-203. 10. Weinberg AD, Pols JK, Levesque PG, Beal LF, Cunningham TJ, Minaker KL. Dehydration and death during febrile episodes in the nursing home. J Am Geriatr Soc 1994; 42: 968-71. 11. McCann RM, Hall WJ, Groth-Junker A. Comfort care for terminally ill patients. The appropriate use of nutrition and hydration. J Am Med Assoc 1994; 272: 1263-6. 12. Byatt CM, Millard, PH, Levin GE. Diuretics and electrolyte disturbances in 1000 consecutive geriatric admissions. J Royal Soc Med 1990; 83: 704-8. 13. MacLennan WJ. Diuretics in the elderly: how safe? Brit Med J 1988; 296: 1551-2. 14. Amella EJ. Feeding and hydration issues for older adults with dementia. Nurs Clin North Am 2004; 39: 607-23. 15. Dyck MJ. Nursing staffing and resident outcomes in nursing homes: weight loss and dehydration. J Nurs Care Qual 2007; 22: 59-65. 16. Phillips PA, Rolls BJ, Ledingham JGG et al. Reduced thirst after water deprivation in healthy elderly men. N Engl J Med 1984; 311: 753-5. 17. Faull CM, Holmes C, Baylis PH. Water balance in elderly people: is there a deficiency of vasopressin? Age Ageing 1993; 22: 114-20. 18. Albert SG, Nakra BRS, Grossberg GT, Caminal ER. Vasopressin response to dehydration in AlzheimerÕs disease. J Am Geriatr Soc 1989; 37: 843-7. 19. Chidester JC, Spangler AA. Fluid intake in the institutionalised elderly. J Am Diet Assoc 1997; 97: 23-8. 20. Thomas DR, Tariq SH, Makhdomm S, Haddad R, Moinuddin A. Physician misdiagnosis of dehydration in older adults. J Am Med Directors Assoc 2004; 5(Suppl 1) S31-4. 21. Chassagne P, Druesne L, Capet C, Menard JF, Bercoff E. Clinical presentation of hypernatraemia in elderly patients: a case control study. J Am Geriatr Soc 2006; 54: 1225-30. 22. Eaton D, Bannister P, Mulley GP, Connolly MJ. Axillary sweating in clinical assessment of dehydration in ill elderly patients. Brit Med J 1994; 308: 1271. 23. Mentes JC, Wakefield B, Culp K. Use of urine color chart to monitor hydration status in nursing home residents. Biol Res for Nursing 2006; 7: 197-203. 24. Colling JC, Owen TR, McCreddy MR. Urine volumes and voiding patterns among incontinent nursing home residents. Residents at highest risk for dehydration are often the most difficult to track. Geriatr Nursing 1994; 15: 188-92. 25. Weinberg AD, Pals JK, McGlinchey-Burroth R, Minaker KL. Indices of dehydration among frail nursing home patients: highly variable but stable over time. J Am Geriatr Soc 1994; 42 1070-3. 26. Spangler PF, Risley TR, Bilyew DD. The management of dehydration and incontinence in nonambulatory geriatric patients. J Appl Behav Analysis 1984; 17: 397-401. 27. Musson ND, Kincaid J, Ryan P et al. Nature, nurture, nutrition; interdisciplinary programs to address the prevention of malnutirition and dehydration. Dysphagia 1990; 5: 96-101. 28. Simmons SF, Alessi C, Schnelle JF. An intervention to increase fluid intake in nursing home residents: prompting and preference compliance. J Am Geriatr Soc 2001; 49: 926-33. 29. Slesak G, Schnurle JW, Kinzel E, Jakob J, Dietz K. Comparison of subcutaneous and intravenous rehydration in geriatric patients: a randomised trial. J Am Geriatr Soc 2003; 51: 155-60. 30. Dasgurta M, Binns MA, Rochon PA. Subcutaneous fluid infusion in a long-term care setting. J Am Geriatr Soc 2000; 48: 795-9. 31. Challiner YC, Jarrett P, Hayward MJ, Al-Jubouri MA, Julious SA. A comparison of intravenous and subcutaneous hydration in elderly acute stroke patients. Postgrad Med J 1994; 70: 195-7. 32. Morley J. Water, water everywhere and not a drop to drink. J Gerontol A Biol Sci Med Sci 2000; 55: M360. 33. Simmons SF, Babineau S, Garcia E, Schnelle JF. Quality assessment in nursing homes by systemic direct observation. Feeding assistance. J Gerontol A Biol Sci Med Sci 2002; 57:M665-71 34. Himmelstein DU, Jones AA, Woolhandler S. Hypernatraemic dehydration in nursing patients: an indicator of neglect. J Am Geriatr Soc 1983; 31: 466-71. Acknowledgment to contributors include: Simone Austin BSc MND: Accredited Practising Dietitian Gerald Quigley: Community Pharmacist Hydralyte Oral Rehydration Solution. Oral Fluid Intake ChartAged Care Facility Patient Name Date //Age Weight kgPatient should drink mls every 60 minutes Recommended fluid requirements 1Patient Weight (kg) !30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 1.7 1.7 1.8 1.9 2.0 2.0 2.1 2.2 2.3 2.3 2.4 2.5 2.6 2.6 2.7 2.8Fluid requirement (litres/day) Time Type of fluid Vomited? Diarrhoea? Urine? Amount of ßuid taken (mls)1 Referenced table 2, Guidelines to Effective Hydration in Aged Care Facilities, Prepared by Associate Professor Michael Woodward. HLYT032_Aged care brochure.indd 10-1113/12/07 9:55:55 AMThe Hydration Pharmaceuticals Trust: Manufacturers of Department of Health and Ageingthe Aged Care Act 1997: 1 July 2009 – 30 June 2010. 2010Report on the operation of

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Oral Fluid Intake Chart(Master copy for photocopying purposes)Aged Care Facility: Patient Name:Date: / /Age: Weight: kg Your patient should drink mLs every 60 minutesTime Type of ßuid Amount of ßuid taken (mLs)Vomited? Diarrhoea?Urine?30354045505560657075808590951001051. ßuid requirements 1Patient Weight (kg) Fluid requirement (litres/days) 1

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