Review on mechanisms, importance of homeostasis and fluid imbalances in the elderly

Water is considered an essential nutrient, but very often is overlooked in favour of nutrition. Due to age related changes, older people are more vulnerable to both, dehydration and overhydration. This article describes the principles of water homeostasis and provides a description of common age-related physiological changes related to water balance. Fluid homeostasis largely depends on osmo- and baro-receptors that respectively react to changes in osmolality and blood pressure, water-regulating hormone release, the subsequent response of kidneys to the hormonal stimulation and activation of thirst. These mechanisms diminish with age and put elderly at risk of dehydration. All involved in a care for the elderly should be informed and become vigilant to prevent dehydration from occurring

Applying human factors ergonomics to the misuse of non-sterile clinical gloves in acute care

Background: Healthcare workers (HCW) are recommended to wear non-sterile clinical gloves (NSCG) for direct contact with blood and body fluids to reduce transmission of healthcare associated infections (HCAI). However, there is evidence that inappropriate NSCG-use increases the risk of transmission. Methods: A mixed methods study comprising observation of NSCG-use during episodes of care in two acute hospitals and semi-structured interviews with HCW. Qualitative data were categorised using thematic analysis. Findings were mapped to the Systems Engineering Initiative for Patient Safety (SEIPS) model and used to develop a strategy for improving NSCG-use. Results: 278 procedures performed in 178 episodes of care involved the use of NSCG. NSCG were inappropriate for 59% (165/278) procedures; risk of cross-contamination occurred in 49% (87/178) episodes. 26 HCW were interviewed; emotion and socialisation were key factors influencing decisions to use NSCG. Data from observation and thematic analysis were mapped to six interacting components of the SEIPS work-system. Interventions targeting each component were identified to inform quality improvement strategies Conclusions: Despite more than a decade of intense promotion of hand hygiene as the key measure to protect patients from HCAI, NSCG dominate routine clinical practice and potential cross-contamination occurs in half of care episodes where they are used. Such practice is associated with significant environmental and financial costs and adversely affects patient safety. The application of HFE to the complex social, professional and emotional drivers of inappropriate NSCG behaviour may be more effective than conventional approaches of education and policy in achieving the goal of preventing HAI and improving patient safety

Methods of assessment of hydration status and their usefulness in detecting dehydration in the elderly

Assessment of hydration status is complex and difficult to achieve. Few assessment methods have been validated to accurately measure the fluid compartments in the body, but they have little application in practice. Different techniques have been developed to determine hydration status for the use in clinical settings, but their diagnostic accuracy remains questionable. Since many experts argue that there is no 'gold-standard' technique and one can never be achieved, this paper describes both, the benefits and limitations of the available methods and their usability in assessing hydration status of the elderly

Public perceptions of the use of gloves by healthcare workers and comparison with perceptions of student nurses

Introduction: There is emerging evidence that non-sterile clinical gloves (NSCG) are over-used by healthcare workers (HCW) and associated with a risk of cross contamination because they are put on too early and removed too late. The purpose of this study was to determine student nurses’ approach to their use and the perceptions and preferences of the public. Methods: A cohort of third-year student nurses were asked to complete a questionnaire and indicate for which of 46 clinical tasks they would routinely wear gloves and what influenced their decision to use them. Factor analysis was used to explore correlations between tasks. Members of the pubic were asked to complete the online survey aiming to explore their recent experiences of healthcare and their attitudes towards HCW wearing gloves. Results: A total of 67 student nurses completed the questionnaire. Inconsistencies in responses were observed and gloves were reported being routinely worn for procedures with a low risk of contact with blood and body fluid. The exploratory factor analysis identified correlations related to four factors – procedures perceived to be risky, definitive indications, procedures related to personal hygiene and some low risk procedures. Most students (94%) indicated their own judgment influenced their decision to wear NSCG. The public survey was completed by 142 people. Many were uncomfortable with HCW using gloves for personal tasks but 94% preferred their use for washing ‘private parts’. Responses were broadly comparable with those of student nurses. 29% had observed inappropriate use of gloves during a recent episode of healthcare treatment and 20% had challenged a HCW about their glove use. Conclusions: Student nurses reported using NSCG appropriately for procedures involving a risk of contact with BBF, however a significant proportion also routinely used NSCG for a wide range of low risk tasks and procedures for which they are neither required nor recommended. Members of the public feel uncomfortable with HCW wearing gloves for some personal care but strongly prefer their use for contact with ‘private parts’ such as the genitals

Nutrition and hydration for older adults living with dementia in care

Undernutrition and dehydration in older adults is of concern for healthcare professionals as well as the individuals and their families. The consequences of undernutrition, which are serious in all ages, however they are especially prominent in the older population. Being generally more vulnerable as well as not being able to recover promptly, older people are at higher risk of falls, more frequent and longer hospital stays, increased infections as well as increased risk of dying. Reduced appetite and thirst along with physical and cognitive impairments can make it difficult for older people to consume sufficient amount of food and fluids. The subsequent adverse events such as falls or infections can further influence nutritional status, creating a vicious cycle of undernutrition and disease. Once established, the cycle is almost impossible to escape. This is a major public concern, not only because quality of life is compromised for those affected but also due to the economic impact that these events have on society. Due to numerous functional and physiological alterations associated with age, older people frequently do not consume sufficient amounts of food and fluid and the diet is usually of poor quality. As a result, the prevalence of macro- and micronutrient undernutrition is high in both free-living and institutionalised older adults. It is estimated that prevalence of protein energy malnutrition may be as high as 15% in community dwelling older people, 25-65% in care home residents and 35-65% in older hospital patients. Early detection of undernutrition may be difficult because it cannot rely solely on anthropometric measurements and needs consideration of other factors. BMI for instance, is an established marker for nutritional status in younger populations but is not useful when assessing nutritional status in older persons. Sarcopenic obesity, which is a common problem within clinical setting and is especially prevalent in older patients, gives the impression that the person is over-nourished due to increased amount of fat mass but is in fact a type of undernutrition arising from an extensive muscle wastage caused by protein deficiency. This type of undernutrition usually occurs as a result of an acute decrease in food intake e.g., due to a sudden illness or food withdrawal. Recovering the muscle mass in older people is difficult, if not impossible in some circumstances. Chronic undernutrition on the other hand depletes all energy stores, leaving a person with little fat and muscle reserves. At this stage, micronutrient deficiencies are also common. People with dementia are particularly vulnerable to chronic undernutrition because they may forget to eat or they may lose the skills necessary for feeding, e.g. how to use the eating utensils

Improving fluid consumption of older people in care homes: an exploration of the factors contributing to under-hydration

Background: Age-related changes which occur in older people put them at risk of dehydration and care home residents are particularly vulnerable. Evidence suggests that hydration care in this setting may be inadequate, but few UK studies have explored the extent of the problem. Aim: To determine the amount of fluids care home residents received and consumed, and identify the barriers and facilitators to optimising hydration care in two private nursing homes to inform the design and implementation of a subsequent service improvement initiative. Methods: A pragmatic descriptive observational design using multiple data collection methods. Results: Mean fluid intake was 1031ml/day; with 50% of residents offered more than 1500ml/day. Residents in communal areas received more drinks than those in their own rooms (74.8% vs 42.6%), and overall residents consumed 69% of fluids they were offered. Those who required assistance to drink consumed the least amount of fluids. Conclusion: Adequately hydrating older people is essential if associated morbidity and hospital admissions are to be prevented. This study has identified the challenges experienced by care homes and residents in meeting this fundamental care need. It demonstrates the importance of a coherent strategy to improve hydration in this population

Joint Healthcare Infection Society (HIS) and Infection Prevention Society (IPS) guidelines for the prevention and control of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities

Meticillin-resistant Staphylococcus aureus (MRSA) infections remain a serious cause of healthcare-associated infection (HCAI) in many countries. MRSA is easily spread by multiple routes and can persist in the environment for long periods. In health and care settings, transmission via staff hands remains the most important route for patient MRSA acquisition. Infection prevention and control (IPC) measures and control of the use of antimicrobials are effective in reducing prevalence of MRSA. There have been many publications related to MRSA since the last guideline was published in 2006 and this update contains further measures that are clinically effective for preventing transmission when used by healthcare workers (Table I). Methods for systematic review were in accordance with National Institute for Health and Care Excellence (NICE) approved methodology and critical appraisal followed Scottish Intercollegiate Guidelines Network (SIGN) and other standard checklists. Articles published between 2004 and February 2021 were included. Questions for review were derived from a stakeholder meeting, which included patient representatives in accordance with the Population Intervention Comparison Outcome(PICO) framework. Recommendations are made in the following areas: screening, management of colonised healthcare staff, environmental screening and cleaning/disinfection, surveillance, IPC precautions (including isolation and movement of patients and equipment), and patient information

I-hydrate training intervention for staff working in a residential care home setting: an observational study

Background Dehydration is a complex and well-recognised problem for older people residing in care homes. Within the social care sector support staff provide the majority of direct care for residents, and yet receive minimal training. Objectives To design, deliver and evaluate a hydration specific training session for care home staff to develop their knowledge and skills in supporting the hydration of care home residents. Design An observational study comprising a pre-test post-test survey of staff knowledge following a training intervention. Participants and Settings Training of care home staff took place in two care homes in North West London. Methods An interactive training session was developed and delivered, with content informed by observations of hydration care within the two homes and evaluated using CIRO model. Participant self-evaluation forms were used to collect data after the session regarding satisfaction and usefulness of the session, and pre and post levels of self-reported knowledge across six facets of hydration care. Training facilitators captured qualitative data in the form of field notes. Observations of hydration care explored the impact of training on practice. Results Eighteen training sessions were delivered. A total of 161 participant evaluation forms were returned. There was a significant increase in self-reported knowledge across all six facets of hydration care (p = 0.000). The majority of participants found the training enjoyable and useful, and expressed an expected change in their practice. Participants enjoyed the interactive components of the training. A lack of reflective practice skills meant participants were unable to reflect realistically about the hydration care provided in the home. Conclusion Providing focused training on hydration in the care home environment benefits from being interactive and experiential. Although such training can be effective in increasing staff knowledge, inclusion of skills in reflective practice is required if this knowledge is to be translated into practice

Improving hydration of care home residents by increasing choice and opportunity to drink: a quality improvement study

Background & Aims: Dehydration is recognised as an important problem among care home residents and can be associated with severe consequences. Insufficient provision of fluids to meet resident preferences and lack of assistance to drink have been identified as key factors driving under-hydration of care home residents. Using targeted interventions, this study aimed to optimise hydration care for frail older people in a care home setting. Methods: The study used quality improvement methods to develop and test interventions to extend drinking opportunities and choice in two care homes. Changes were made and evaluated using Plan-Do-Study-Act (PDSA) cycles. Data were captured on the amount of fluids served and consumed, and staff and resident feedback. The long-term impact of the interventions was assessed by measuring daily laxative and antibiotic consumption, weekly incidence of adverse health events, and average fluid intake of a random sample of six residents captured monthly. Results: The interventions were associated with an increase in the amount and range of fluids consumed, in one home mean fluid intakes exceeded 1500ml for three consecutive months. Laxative use decreased significantly in both homes. A number of practical and organisational barriers affected the sustainability of interventions. Conclusions: Interventions to optimise the hydration of care home residents can be effective. Plan-Do-Study-Act cycles provide an effective methodology to implement new interventions into existing practice in care homes. Sustainable change requires strong leadership, organisational support and teamwork