Understanding, recognising and preventing dehydration in older residents living in care homes: a mixed methods study

Abstract Aim To recognise and understand how to prevent water-loss dehydration occurring in older people living in care homes. Background Water-loss dehydration is common and linked to poor drinking, but prevention is likely to be multi-faceted. Methods Three independent studies investigating hydration care in older care home residents were conducted and the findings integrated (mixed methods, convergent parallel design): Diagnostic accuracy of clinical signs and symptoms of dehydration. Systematic review investigating effectiveness of interventions and associations of modifiable environmental factors on improving fluid intake and/or hydration status. Qualitative study involving residents, families and care-staff in focus groups, exploring challenges and facilitators in hydration care. Results In the diagnostic accuracy study, 188 residents (mean age 85 years, 66% women) were recruited from 56 care homes. Clinical signs and symptoms were ineffective in identifying older people with dehydration. The 23 included studies in the systematic review addressed a range of strategies at carer, institutional and societal (‘macro’) levels to improve fluid intake and hydration status, but high risk of bias in many studies meant findings were inconclusive. Three themes emerged from the qualitative study: ‘meanings and experiences of drinking’, ‘caring roles’, and ‘tensions and barriers to successful drinking’. Integrated findings identified residents’ and families’ contributions to residents’ hydration care and preventing dehydration requires a multi-faceted approach. The researcher-led quantitative studies of the systematic review indicated how macro factors may impact on hydration care (along with institutional and carer-led factors). Findings from the diagnostic accuracy should inform national guidelines at the macro level. The qualitative study provided experiential perspectives and insights into relational care between each care level and how these have positive and negative impacts on residents’ drinking. Conclusion Fluid intake is a physiological necessity to prevent dehydration. Supporting care home residents to drink involves multi-levels of care and is a social experience. (300 words) Medline medical subject headings (MeSH): aged; beverages; dehydration; diagnostic tests, routine; drinking; geriatrics; long-term care; osmolar concentration; qualitative research; residential facilities; review, systematic

Beverage Intake and Drinking Patterns—Clues to Support Older People Living in Long-Term Care to Drink Well: DRIE and FISE Studies

Low-intake dehydration, due to insufficient beverage intake, is common in older people and associated with increased mortality and morbidity. We aimed to document drinking patterns of older adults living in long-term care and compared patterns in those drinking well with those not drinking enough. 188 people aged ≥ 65 years living in 56 UK long-term care homes were interviewed and hydration status assessed in the Dehydration Recognition In our Elders (DRIE) study. In 22 DRIE residents, the Fluid Intake Study in our Elders (FISE) directly observed, weighed and recorded all drinks intake over 24-hours. Twenty percent of DRIE participants and 18% of FISE participants had low-intake dehydration (serum osmolality > 300 mOsm/kg ). Mean total drinks intake was 1787 mL/day (SD 693) in FISE participants (2033 ± 842 mL/day in men; 1748 ± 684 mL/day in women). Most drinks intake was between meals (59%, including 10% with medications). Twelve (55%) FISE participants achieved European Food Safety Authority drinks goals (3/6 men drank ≥ 2.0 L/day , 9/16 women drank ≥ 1.6 L/day). Those drinking well were offered beverages more frequently, drank more with medications and more before breakfast (beverage variety did not differ). Promising strategies to support healthy drinking include offering drinks more frequently, particularly before and during breakfast and with medication

Signs and symptoms of low-intake dehydration do not work in older care home residents - DRIE diagnostic accuracy study

Objectives: To assess the diagnostic accuracy of commonly used signs and symptoms of low-intake dehydration in older care home residents. Design: Prospective diagnostic accuracy study. Setting: 56 care homes offering residential, nursing, and/or dementia care to older adults in Norfolk and Suffolk, United Kingdom. Participants: 188 consecutively recruited care home residents aged ≥65 years, without cardiac or renal failure and not receiving palliative care. Overall, 66% were female, the mean age was 85.7 years (standard deviation 7.8), and the median Mini-Mental State Examination MMSE score was 23 (interquartile range 18-26). Index tests: Over 2 hours, participants underwent double-blind assessment of 49 signs and symptoms of dehydration and measurement of serum osmolality from a venous blood sample. Signs and symptoms included skin turgor; mouth, skin, and axillary dryness; capillary refill; sunken eyes; blood pressure on resting and after standing; body temperature; pulse rate; and self-reported feelings of thirst and well-being. Reference standard: Serum osmolality, with current dehydration defined as >300 mOsm/kg, and impending dehydration ≥295 mOsm/kg. Outcome measures: For dichotomous tests, we aimed for sensitivity and specificity >70%, and for continuous tests, an area under the curve in receiver operating characteristic plots of >0.7. Results: Although 20% of residents had current low-intake dehydration and a further 28% impending dehydration, none of the commonly used clinical signs and symptoms usefully discriminated between participants with or without low-intake dehydration at either cut-off. Conclusions/implications: This study consolidates evidence that commonly used signs and symptoms of dehydration lack even basic levels of diagnostic accuracy in older adults, implying that many who are dehydrated are not being identified, thus compromising their health and well-being. We suggest that these tests be withdrawn from practice and replaced with a 2-stage screening process that includes serum osmolarity, calculated from sodium, potassium, urea, and glucose levels (assessed routinely using the Khajuria and Krahn equation), followed by serum osmolality measurement for those identified as high risk (calculated serum osmolarity >295 mmol/L)

Aphid Pests on Vegetables

This fact sheet provides information on four of the most common aphids that are pests of vegetable crops in Utah: green peach aphid, potato aphid, melon or cotton aphid, and cabbage aphid

Direct health costs of inflammatory polyarthritis 10 years after disease onset:Results from the Norfolk Arthritis Register

Objectives: To explore the change in direct medical costs associated with inflammatory polyarthritis (IP) 10 to 15 years after its onset. Methods: Patients from the Norfolk Arthritis Register who had previously participated in a health economic study in 1999 were traced 10 years later and invited to participate in a further prospective questionnaire-based study. The study was designed to identify direct medical costs and changes in health status over a 6-month period using previously validated questionnaires as the primary source of data. Results: A representative sample of 101 patients with IP from the 1999 cohort provided complete data over the 6-month period. The mean disease duration was 14 years (SD 2.1, median 13.6, interquartile range 12.6–15.4). The mean direct medical cost per patient over the 6-month period was £1496 for IP (inflated for 2013 prices). This compared with £582 (95% CI £355–£964) inflated to 2013 prices per patient with IP 10 years earlier in their disease. The increased cost was largely associated with the use of biologics in the rheumatoid arthritis subgroup of patients (51% of total costs incurred). Other direct cost components included primary care costs (11%), hospital outpatient (19%), day care (12%), and inpatient stay (4%). Conclusion: The direct healthcare costs associated with IP have more than doubled with increasing disease duration, largely as a result of the use of biologics. The results showed a shift in the direct health costs from inpatient to outpatient service use

Increasing fluid intake and reducing dehydration risk in older people living in long-term care: a systematic review

Objective: To assess the efficacy of interventions and environmental factors on increasing fluid intake or reducing dehydration risk in older people living in long-term care facilities. Design: Systematic review of intervention and observational studies. Data Sources: Thirteen electronic databases were searched from inception until September 2013 in all languages. References of included papers and reviews were checked. Eligibility criteria: Intervention and observational studies investigating modifiable factors to increase fluid intake and/or reduce dehydration risk in older people (≥65 years) living in long-term care facilities who could drink orally. Review methods: Two reviewers independently screened, selected, abstracted data and assessed risk of bias from included studies, narrative synthesis was performed. Results: 4328 titles and abstracts were identified, 325 full-text papers obtained and 23 included in the review. Nineteen intervention and 4 observational studies from 7 countries investigated factors at resident, institutional or policy level. Overall the studies were at high risk of bias due to selection and attrition bias and lack of valid outcome measures of fluid intake and dehydration assessment. Reported findings from six of the nine intervention studies investigating the effect of multi-component strategies on fluid intake or dehydration described a positive effect. Components included greater choice and availability of beverages, increased staff awareness, increased staff assistance with drinking and toileting. Implementation of the US Resident Assessment Instrument reduced dehydration prevalence from 3% to 1%, p=0.01. Two smaller studies reported positive effects, one on fluid intake in 9 men with Alzheimer's Disease using high-contrast red cups, the other involved supplementing 13 mildly dehydrated residents with oral hydration solution over 5 days to reduce dehydration. Modifications to the dining environment, advice to residents, presentation of beverages and mode of delivery (straw vs beaker; pre-thickened drinks vs those thickened at the bedside) were inconclusive. Two large observational studies with good internal validity investigated effects of ownership; in Canada, for-profit ownership was associated with increased hospital admissions for dehydration; no difference was seen in dehydration prevalence between US for-profit and not-for-profit homes, although chain facilities were associated with lower odds of dehydration. This US study did not suggest any effect of staffing levels on dehydration prevalence. Conclusions: A wide range of interventions and exposures were identified, but the efficacy of many strategies remains unproven due to the high risk of bias present in many studies. Reducing dehydration prevalence in long-term care facilities is likely to require multiple strategies involving policymakers, management and care staff, but these require further investigation using more robust study methodologies. Systematic review registration: The review protocol was registered with the International Prospective Register of Systematic Reviews (http://www.crd.york.ac.uk/PROSPERO/display_record.asp? ID=CRD42012003100)

Care-home Nurses' responses to the COVID-19 pandemic: Managing ethical conundrums at personal cost: A qualitative study

Introduction: The COVID-19 pandemic had an unprecedented effect on those living and working in care-homes for older people, as residents were particularly vulnerable to contracting the SARS-CoV-2 virus, associated with high morbidity and mortality. Often undervalued, care-home nurses (RNs) are leaders, managing complex care while working in isolation from their professional peers. The pandemic made this more apparent, when care and treatments for COVID-19 were initially unknown, isolation increased due to withdrawal of many professional health services, accompanied by staff shortages. Objective: To explore RNs' experiences of working in older people's care-homes during the COVID-19 pandemic. Design: Qualitative interview study. Setting: Care-homes for older people in England and Scotland, UK. Methods: Recruitment via direct contact with care-homes, social media, and links provided by national partners, then purposive sampling for age, gender, type of care-home, and location. Data collected through one-to-one online interviews using topic guide developed collaboratively with care-home nurses, focusing on how COVID-19 impacted on nurses' resilience and mental wellbeing. Data analyzed thematically using Tronto's ethics of care framework to guide development of interpretative themes. Results: Eighteen nurses (16 female; 16 adult, and two mental health nurses) were interviewed March–June 2021; majority aged 46–55 years; mean time registered with Nursing and Midwifery Council: 19 years; 17 had nursed residents with COVID-19. RNs' experiences resonated with Tronto's five tenets of ethical care: attentiveness, responsibility, competence, responsiveness, and solidarity. All nurses described being attentive to needs of others, but were less attentive to their own needs, which came at personal cost. RNs were aware of their professional and leadership responsibilities, being as responsive as they could be to resident needs, processing and sharing rapidly changing guidance and implementing appropriate infection control measures, but felt that relatives and regulatory bodies were not always appreciative. RNs developed enhanced clinical skills, increasing their professional standing, but reported having to compromise care, leading to moral distress. Broadly, participants reported a sense of solidarity across care-home staff and working together to cope with the crisis. Conclusion: Care-home nurses felt unprepared for managing the COVID-19 pandemic, many experienced moral distress. Supporting care-home nurses to recover from the pandemic is essential to maintain a healthy, stable workforce and needs to be specific to care-home RNs, recognizing their unique pandemic experiences. Support for RNs will likely benefit other care-home workers either directly through wider roll-out, or indirectly through improved wellbeing of nurse leaders. Clinical relevance: The COVID-19 pandemic, an international public health emergency, created many challenges for Registered Nurses (RNs) working in long-term care facilities for older people, as residents were particularly vulnerable to the impact of the SARS-CoV-2 virus. Care-home RNs faced challenges distinct from their hospital-based nursing peers and non-nursing social care colleagues due to their isolation, leadership roles, professional legal obligations, and ethical responsibilities, leading to psychological distress on the one hand, but also a newly found confidence in their existing and newly developed skills, and increased recognition by the wider health community of their specialisms