A three-dimensional approach to hydration of elders: administration, clinical staff, and in-service education

Integration of a new technology into a work system: a case study of a smart drinking glass in French nursing homes

PURPOSE

To reduce the risk of dehydration in older adults, the French company Auxivia has developed a smart drinking glass (SDG) that can measure the amount of water drunk. The present study looked at the various work systems (WSs) designed for use of the SDG in a nursing home. The study's objectives were to (i) determine the WSs' impact on the staff's ability to comply with the device's prerequisites and ensure the device's effective use and (ii) draw up guidelines on designing work systems.

MATERIALS AND METHODS

At three nursing homes in France, two independent observers performed 9 h of observations at each site and a total of 29 interviews.

RESULTS

Decisions concerning implementation and the resulting WSs have an impact on the tasks to be performed, the tasks' inherent constraints and the use of the SDG. It is essential to take account of the sociotechnical system as a whole before integrating a technology. Ideally, the introduction of an SDG will go unnoticed by staff and residents; however, our results emphasize the value of highlighting work constraints via a human factors analysis.

CONCLUSIONS

It is essential to take account of sociotechnical WSs as a whole when integrating a technology.

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.

How and why are subcutaneous fluids administered in an advanced illness population: a systematic review

AIMS AND OBJECTIVES

To identify the mechanisms of subcutaneous fluid administration in advanced illness.

BACKGROUND

Hydration at end of life is a fundamental issue in quality care internationally. Decision-making regarding the provision of artificial hydration in advanced illness is complicated by a paucity of evidence-based guidance. Despite considerable attention given to the topic including two recent Cochrane reviews, there has been no focus in systematically identifying papers that report the mechanisms for delivering hydration subcutaneously. Consequently, there is a need to produce guidance on the site, mode, volume and rate of infusion, based on empirical evidence.

DESIGN

Systematic review of papers reporting empirical research data.

METHODS

Key databases (CENTRAL, Medline, EMBASE, Web of Science, CINAHL) were searched in September 2015, with no date limitations. Inclusion criteria focused on hypodermoclysis in adults within an advanced illness population. Selected studies were reviewed for quality and a risk-of-bias assessment was conducted for the included studies.

RESULTS

Fourteen papers were included in the analysis; most (n = 8) were conducted in hospices with others (n = 6) in long-stay units with a population affected by chronic conditions associated with ageing. Studies were of moderate or high quality. The site and mode of infusion were not well described in these papers, and rates of infusion varied widely allowing for little clear consensus to guide clinical practice in the administration of subcutaneous fluids.

CONCLUSIONS

Studies under-report the mechanisms by which artificial hydration is provided, creating a paucity of evidence-based guidance by which to practice. There is a need for evidence generated from nonmalignant populations to ensure applicability to the large number of people with other advanced illness.

RELEVANCE TO CLINICAL PRACTICE

In the absence of sufficiently powered robust evidence, the mode of delivery of artificial hydration at end of life remains in the gloaming between evidence and unfounded habit.

Clinical assessments and care interventions to promote oral hydration amongst older patients: a narrative systematic review

BACKGROUND

Older patients in hospital may be unable to maintain hydration by drinking, leading to intravenous fluid replacement, complications and a longer length of stay. We undertook a systematic review to describe clinical assessment tools which identify patients at risk of insufficient oral fluid intake and the impact of simple interventions to promote drinking, in hospital and care home settings.

METHOD

MEDLINE, CINAHL, and EMBASE databases and two internet search engines (Google and Google Scholar) were examined. Articles were included when the main focus was use of a hydration/dehydration risk assessment in an adult population with/without a care intervention to promote oral hydration in hospitals or care homes. Reviews which used findings to develop new assessments were also included. Single case reports, laboratory results only, single technology assessments or non-oral fluid replacement in patients who were already dehydrated were excluded. Interventions where nutritional intake was the primary focus with a hydration component were also excluded. Identified articles were screened for relevance and quality before a narrative synthesis. No statistical analysis was planned.

RESULTS

From 3973 citations, 23 articles were included. Rather than prevention of poor oral intake, most focused upon identification of patients already in negative fluid balance using information from the history, patient inspection and urinalysis. Nine formal hydration assessments were identified, five of which had an accompanying intervention/ care protocol, and there were no RCT or large observational studies. Interventions to provide extra opportunities to drink such as prompts, preference elicitation and routine beverage carts appeared to support hydration maintenance, further research is required. Despite a lack of knowledge of fluid requirements and dehydration risk factors amongst staff, there was no strong evidence that increasing awareness alone would be beneficial for patients.

CONCLUSION

Despite descriptions of features associated with dehydration, there is insufficient evidence to recommend a specific clinical assessment which could identify older persons at risk of poor oral fluid intake; however there is evidence to support simple care interventions which promote drinking particularly for individuals with cognitive impairment.

TRIAL REGISTRATION

PROSPERO 2014:CRD42014015178.

An exploration of the hydration care of older people: a qualitative study

BACKGROUND

Older adults are more susceptible to water imbalance and ensuring they drink sufficiently is a complex and challenging issue for nurses. The factors that promote adequate hydration and the barriers which prevent older people from drinking are not well understood.

OBJECTIVE

This study aimed to understand the complexity of issues associated with the hydration and hydration care of older people.

DESIGN

A qualitative study using multiple methods.

SETTINGS

Two healthcare sites providing care for older people in the South West of England: a hospital ward in a major hospital and a care home providing personal and nursing care.

PARTICIPANTS

Twenty-one older people aged 68-96 years, were recruited to the study from the hospital ward and care home. The inclusion criteria for older people to participate were men or women aged 65 years and over and the exclusion criteria were being unable to provide informed consent, or being too ill or distressed to take part in the study. The staff participants of nurses and health care assistants totalled 21. The inclusion criterion for staff was any nurse or health care assistant providing hydration care. Seven friends or relatives participated by making anonymous comments via a suggestion box available to all friends and relatives.

METHODS

Data were collected via interviews with older people, focus group discussions involving staff, suggestion box comments made by friends and relatives and twelve hours observation of hydration practice. The data were analysed using thematic analysis.

RESULTS

Health professionals successfully employed several strategies to promote drinking including verbal prompting, offering choice, placing drinks in older people's hands and assisting with drinking. Older people revealed their experience of drinking was diminished by a variety of factors including a limited aesthetic experience and a focus on fluid consumption rather than on drinking as a pleasurable and social experience.

CONCLUSION

The rich and varied dimensions usually associated with drinking were lacking and the role of drinking beverages to promote social interaction was underplayed in both settings. Hydration practice which supports the individual needs of older people is complex and goes beyond simply ensuring the consumption of adequate fluids.

Feeding and hydration issues for older adults with dementia

All cultures dictate the need to feed the hungry and create rituals for almost every life passage around the consumption of food and beverage. Yet, in old age and among those who cannot advocate for themselves, mealtime is medicalized and demoted to an insignificant event without dignity or regard for individualized needs. Attention must be paid to not only what people eat, but how they eat, and how they are supported in that process. Kayser-Jones summarized the extensive findings of several ethnographic studies in nursing homes by noting the multi-factorial issues involved in delivering excellent care to all residents, especially those lacking an advocate. Her findings exposed how lack of staff education, inadequate staffing and supervision, disregard for personal and cultural preferences, lack of assessment for comorbid health problems, intake of food and fluids, dysphagia, and oral health problems all contributed to malnutrition and dehydration among the residents studied. This seminal set of studies, along with Dr. Kayser-Jones' testimony in US Congressional hearings directly affected the design of federal regulatory protocols to address malnutrition and dehydration. In an attempt to increase the number of staff available to assist at meals, the Centers for Medicare and Medicaid issued a change in regulations on Sept. 26, 2003, allowing reimbursement for staff trained for a total of 8 hours to act as feeding assistants. This change is intended to, "provide more residents with help in eating and drinking and reduce the incidence of unplanned weight loss and dehydration". Although seen as answering some of the staffing ratio issues at meal times,this rule change has been criticized for not addressing the complexities of resident needs at meal times. Although offering food and fluid is time-consuming and requires special knowledge of physiological changes and empathy for persons whose behavior might be objectionable at times, it may be one of the few times during the day that the individual with dementia receives normalized social interaction. Thus, as in the care of all vulnerable persons with dementia, whether at home or in an institution, perhaps the greatest challenge and need is for nurses and other caregivers to provide a social environment that promotes individual dignity and comfort.

Can a beverage cart help improve hydration?

The purpose of this study was to determine the effectiveness of a hydration program to improve hydration and prevent conditions associated with dehydration (delirium, urinary tract infections, respiratory infections, falls, skin breakdown, and constipation). Data showed a significant increase in fluid in each body compartment, significant decrease in the number of laxatives, increase in the number of bowel movements, decline in the number of falls, and decrease in cost during the hydration period.

Quantifying fluid intake in dysphagic stroke patients: a preliminary comparison of oral and nonoral strategies

OBJECTIVE

To determine whether dysphagic stroke patients receiving oral (thickened-fluid dysphagia) diets or nonoral (enteral feedings supplemented with intravenous fluids) diets met their estimated fluid requirements.

DESIGN

Cohort study.

SETTING

University-affiliated hospital.

PARTICIPANTS

Thirteen dysphagic patients with new strokes were studied for 21 days postadmission to hospital.

INTERVENTIONS

Seven patients (group 1) were started on nonoral feeding and later progressed to oral diets and 6 patients (group 2) received oral dysphagia diets only.

MAIN OUTCOME MEASURE

Fluid intake.

RESULTS

Fluid intake of patients in group 1 significantly declined over the 21 days (mean +/- standard deviation, 3158 +/- 523mL/d vs 984 +/- 486mL/d; p < .0001), representing 134% +/- 26% and 43% +/- 20% of their fluid requirements, respectively. Mean fluid intake of patients in group 2 was 755 +/- 162mL/d, representing 33% +/- 5% of requirements. This volume was significantly lower than the fluid intake of patients who received nonoral feeding (p < .0001).

CONCLUSIONS

Dysphagic stroke patients who received thickened-fluid dysphagia diets failed to meet their fluid requirements whereas patients on enteral feeding and intravenous fluid regimens received ample fluid.

Water intake of nursing home residents

This study describes the adequacy of water intake among nursing home residents and identifies variables associated with the adequacy of water intake. Ninety-nine nursing home residents were observed for two 24-hour periods to record food and fluid ingested, ingestion behaviors, and function. Mean water intake (based on food and fluid) was 1,968 mL per day, ranging from 597 mL to 2,988 mL. Only eight subjects met their standard water requirement of 1,600 mL/m2 body surface area. Subjects with inadequate water intake were older, more independent, had few ingestion sessions per day, had intact speech, were semidependent with eating, did not drool, and had inadequate nutrient intake.