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Prevention through hydration

Professor Jennie Wilson, a member of the Infection Prevention Society, discusses the importance of hydration, especially in older patients, in infection prevention and control.

Hydration needs to be a priority for carers and clinicians, especially for those looking after more vulnerable groups such as the elderly. Hydration is important because dehydration is linked to an increased risk of urinary tract infections and, in the elderly, has also been associated with a risk of falls and confusion. As healthcare professionals, we need to be aware of the factors contributing to patients not drinking enough and ensure they stay hydrated.

Fluids in the body are important to keep your tissues healthy. They need to be frequently replenished as they are continually eliminated through our kidneys, gut or skin.

Older people are particularly vulnerable to dehydration because they lose more fluid as their kidney function declines with age. As you get older you can also lose your thirst reflex – meaning older people may not recognise when they are becoming dehydrated and that they need to drink more fluids.

Physical and cognitive deterioration can make these problems worse, and lead to older people encountering practical challenges in taking in enough fluids.

For example, they may find it difficult to make drinks for themselves, fill and turn on a kettle, or pick up and hold a cup. If their mobility is limited it might also be difficult for them to get to the shops to buy their preferred drinks, and they may not be able to move easily between rooms to make drinks.

The role of carers

These problems may affect both older people in their own homes and those in hospital or care home environments, where they may be dependent on care staff to provide and assist with drinks.

Whether at home or in a care setting, the onus is on carers and healthcare professionals to help and encourage people to drink enough.

Even if an older person doesn’t indicate they are thirsty, carers still need to encourage them to drink and emphasise the importance of staying hydrated to avoid harmful effects.

Anxiety about the risk of incontinence is another factor contributing to poor fluid intake in older people. For example, older men with enlarged prostates or women with impaired pelvic floor muscles may experience urgency or frequency in passing urine.

Older people may be worried about getting to the toilet in time, particularly if they can’t get there on their own. Incontinence can cause huge worry and embarrassment and, as a result, people may restrict the amount they drink to avoid going to the toilet.

For those being cared for in their own home, this concern may be increased by the fact that they only have a carer a few times a day.

If they their mobility is impaired, they may entirely rely on their carer to help them get to the toilet, therefore avoiding drinking until they know their carer is on hand.

It is generally accepted that adults need at least 1,500ml a day to stay hydrated. Yet research shows that in a care home setting, many residents drink much less than this, around only 1,000ml per day.

If you think about how frequently fluids are offered to patients in a typical care environment, and add those opportunities up, there simply aren’t enough drink rounds in the day to ensure that patients get the amount they need to drink.

A small cup of fluid will be 150ml and a mug will be 200ml, so you would need eight mugs of fluid in order to get the minimum needed intake of 1,500ml.

Since in most care settings there are no more than five rounds of drinks offered each day (breakfast, mid-morning, lunch, mid-afternoon and dinner), the residents or patients will only consume 1,000ml if they are served only one drink at each opportunity.

Often, they will drink less than a full cup, particularly if they need a carer to help or remind them to drink. Although serving fluid in a beaker might seem an easy way for older people to manage drinking on their own, these are not only not nice to drink from, but can be harmful for people with swallowing difficulties.

Ensuring your patients or residents drink enough every day can be challenging, but there are a few simple things you can do to support them:

• Consider how many times they are offered drinks during the day and think about how you might add an extra round of drinks, e.g. offer drinks both before and after meals;
• Ensure more than one drink is offered at each drinks round, e.g. a hot and a cold drink or refills;
• Identify those patients/residents who need help to hold a cup or prompting to finish their drink, and make sure someone is available for a few minutes to help them drink regularly through-out the day. Avoid using beakers;
• Offer more foods that contains a lot of fluids such as jelly, ice cream, yoghurt or custard;
• For patients/residents with concerns about incontinence, discuss with them how this can best be managed, reinforce the importance of drinking enough, and reassure them that they can ask for help to get to the toilet;
• For patients in their own home, think about ways that drinks can be made more readily accessible for them, e.g. thermos flasks or water bottles. Emphasise how important it is that they drink enough. Discuss with their relatives and care staff how they can be supported to get enough drink and, if relevant, how to address their worries about getting to the toilet.

Hydration is a very basic care need but we need to think more carefully about how to ensure that our patients/residents get enough to drink every day.

By doing all we can to keep patients hydrated, we can help avoid infections and keep patients healthier for longer.

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