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According to Age UK, 1 in 10 older people are undernourished. Of these, over 90% live in the community rather than in residential elderly care. Also, the NHS states that 35% of those admitted to care homes are also affected by malnutrition. With over 3 million people at risk of malnutrition in the UK, it is important to promote good practice and the importance of hydration and nutrition in care as well as raise awareness of the risks that dehydration and malnutrition can bring.
What are hydration and nutrition?
In the UK, the 14th to 20th March 2022 is Nutrition and Hydration Week. Every year since 2012, health and social care providers have used this week to highlight issues with nutrition and hydration in care as well as promote initiatives that strive for improvement. It is also an opportunity for providers to celebrate improvements that have happened in the provision in the local area or even nationally and globally.
Why is hydration and nutrition in care important?
Jane Cummings, Chief Nursing Officer for England, explains:
“The link between nutrition and hydration and a person’s health is a fundamental part of any stage of life, but all the more so for the sick or vulnerable.”
Preventing dehydration and malnutrition in care is imperative as good hydration and nutrition improve health and well-being for those receiving care as well as helping to ease the burden that treating conditions associated with malnourishment and dehydration bring.
As the NHS guidance on nutrition and hydration explains, malnutrition and dehydration cause illness and are also a consequence of it. They both have a considerable impact on health outcomes and are vital in care. Indeed, it is of some surprise that malnourishment and dehydration are still not well recognised in community or healthcare settings even though there have been many reports that have highlighted the often-inadequate nutrition and hydration that those in these settings receive.
As such, it is important that managing hydration and nutrition in care settings is improved, not only for those on the receiving end of care but also for the wider benefits that it will have on the NHS. The NHS guidelines quote some important research:
The cost for disease-related malnutrition for health and social care expenditure is more than £13 billion. (Elia and Russell for BAPEN, 2009).
Improving the identification and treatment of malnutrition is estimated to have the third highest potential to deliver cost savings to the NHS. (The National Institute for Health and Care Excellence (NICE), 2011).
In looking at such research, it is not difficult to see why hydration and nutrition are of utmost importance in care.
What is good nutrition?
Nutrition is important for anyone, no matter their age. Each day, we get our fuel and energy from food, and we need to ensure that we have a good balance of nutrients within that food to be healthy. For older people, body changes result in lower energy needs in the form of calories. Many older people find themselves only needing smaller meals. This is one reason why it is so important for older people to have good nutrition in the form of a balanced diet.
Good nutrition includes elements from all food groups: fruits and vegetables, proteins, carbohydrates, fats and oils, and dairy products. By consuming something from each of the food groups, it should provide the key vitamins and minerals that we all need. Good nutrition should encompass lots of home-cooked, good-quality foods including whole grains and leaner meats.
It should also involve avoiding some foods such as saturated fats and salt which can cause or exacerbate health conditions such as high blood pressure or heart disease, which are often common ailments in older people.
For those receiving elderly care, whether in the community or residential care, access to good nutrition is often out of their control. The research above suggests that those in the community are more likely to suffer from poor nutrition, and this is likely not surprising for many.
Those without family support may opt for pre-prepared food that is easy to eat. Additionally, many older people receive some care and are on the poverty line. Accessing good-quality food may be a stretch to their budget.
Why is good nutrition important in care?
Given that the UK population is ageing, the cost of care in the long term is becoming unaffordable. As such, it is important that people age well so that their care needs are reduced in later life. Ensuring good nutrition is one way in which this can be achieved.
As mentioned, the evidence suggests that having poor nutrition causes significant health problems, particularly for those receiving care. Health problems associated with poor nutrition include heart disease, diabetes and osteoporosis. Additionally, poor nutrition means that a person is much more likely to pick up infections and colds.
The Government suggests that poor nutrition results in more frequent use of healthcare. According to research, this equates to an average of 65% more visits to a GP, 82% more admissions to hospital, and a 30% longer stay in hospital.
Malnourishment increases a person’s risk of becoming frail, which is detrimental to their overall health and well-being. Spotting malnutrition and then treating it is a vital way of protecting and preventing older people from frailty and resulting ill health. Maintaining good nutrition, and therefore good health, reduces the need for care.
Signs and symptoms of poor nutrition in care
Poor nutrition is also known as malnutrition. NICE defines malnutrition as:
“a state in which a deficiency of nutrients such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function (including social and psychological) and clinical outcome.” (NICE, 2012).
Identifying malnutrition is not always as simple as looking for someone having lost weight. It is important that care providers, and families too, can spot the signs and symptoms associated with poor nutrition.
- Weight changes.
- Lethargy or tiredness.
- Muscle weakness.
- Increased falls.
- Changes in bowel habits, such as increased constipation.
- Pressure sores and poor skin.
- Mood changes such as depression.
- Memory loss, cognitive problems or changes in behaviour.
- Increased infections.
Poor nutrition in care has many causes. Older people may forget to eat due to cognitive problems such as dementia. If an older person takes medication for any reason, this could also cause changes to their appetite. There may also be physical challenges to obtaining good nutrition such as having dentures that fit poorly or having dental problems.
Previous strokes or other health problems may also have caused chewing or swallowing difficulties. There may also be issues with the physical task of eating too due to sight issues or being unable to lift cutlery or drinks. Many older people are proud and feel embarrassed at making a mess whilst they eat. All the reasons are important considerations when identifying someone in care who has or is at risk of suffering from poor nutrition.
What is hydration?
It is a fairly well-known fact that the human body is made up of over 50% water, and that the body needs water for most of its functions. Many of us aim to consume around eight glasses or two litres of water every day. Many people become dehydrated by not drinking enough during the day or by losing fluids and not replacing them.
Why is good hydration important in care?
Good hydration is vital in care settings. It maintains all bodily functions including muscles, brain and heart. By maintaining healthy levels of fluid in the body, a person reduces their risk of contracting infections, particularly urinary tract infections (UTIs).
For most of us, urine infections are fairly minor ailments that are treated successfully with antibiotics. However, for the elderly, urinary infections can be very dangerous. They are also much more common as you age. Over a third of infections in those in nursing homes are UTIs.
This is due to the fact that older people tend to have other conditions that increase their risk of UTIs (such as an enlarged prostate in men or post-menopausal changes to genital tissues in women). This is why good hydration is vital for older people and those in care.
Older people are often less aware that they are becoming dehydrated. They do not always recognise thirst, and some may be unable to communicate their need for fluids. Being able to recognise the signs of dehydration is imperative in care.
Signs and symptoms of dehydration in care
The NHS defines dehydration as:
“a state in which a relative deficiency of fluid causes adverse effects on function and clinical outcome. In the elderly, being short of fluid is far more common, results from limited fluid intake, and is reflected in raised osmolality.”
According to the British Nutrition Foundation, older people are increasingly vulnerable to dehydration as a result of physiological change as we age. This can also be complicated by disease as well as physical and mental frailty. Older people often have a reduced sensation of thirst and so it is often not the most reliable indicator of dehydration.
Recognising dehydration in care is essential. Preventable dehydration in care settings such as hospitals or care homes indicates poor quality of care. Despite it being preventable, it is still common.
Here are some of the signs and symptoms of dehydration in care:
- Dry mouth.
- Infrequent passing of urine or passing small amounts.
- Darker urine colour.
- Muscle cramps.
- A drop in blood pressure (and becoming dizzy and unbalanced).
- Mood changes.
- Mobility changes.
- Urinary Tract Infections (UTIs).
As has been alluded to, there are significant consequences of dehydration. It is associated with increased hospitalisation, increased mortality and generally poor health outcomes. It has been reported that there is a two-fold increase in mortality for stroke patients due to dehydration.
Mild dehydration is not without problems too. It can increase tiredness and affect a person’s mental functions including concentration, memory and attention. It increases the risk of falls as well as a person’s susceptibility to skin conditions or pressure sores.
How to manage hydration and nutrition in care
Managing hydration and nutrition in care is vital to help older people reduce their risk of malnutrition and dehydration.
To manage hydration, several things can help:
- Training for all staff (not just carers) in care settings to recognise the signs and symptoms of malnutrition and dehydration as well as informing them as to why they are of utmost importance.
- Creating a plan for each person with an individualised goal for fluid intake.
- Offering a variety of fluids, including those that the person prefers.
- Ensuring water offered to drink looks pleasant and refreshing (by adding ice or lemon for example).
- Having drinks available at all times, not just at set times.
- Offering fluids to those in care regularly or reminding them to drink if needed.
- Having a fluid intake routine such as always offering a drink after a particular session or activity.
- Assisting if someone is unable to drink easily and offering aids to help such as adapted cups.
- Offering a full glass of fluid when taking medications.
In terms of nutrition, there are small changes that caregivers can make to help manage the risk of malnutrition.
These can include:
- Offering choices at mealtimes.
- Offering softer foods such as beans, eggs, cooked vegetables, mashed potatoes and tinned fruit.
- Offering smaller, more regular meals than the standard three big meals a day.
- Eating in a group setting and making it a social occasion so that it is enjoyable.
- Seeking help from professionals if someone is lacking in particular nutrients.
- In a residential care setting, carefully planning the menu to include all food groups whilst providing choice.
- Ensuring that care settings maintain rigorous food safety and hygiene when it comes to preparing food.
Managing hydration and nutrition in care is of utmost importance. By managing as well as promoting hydration and nutrition in care settings, we are not only reducing the risks of malnutrition and dehydration for elderly people, but we are also having a positive impact on the NHS.
Malnutrition and dehydration are problems that should be relatively easy to resolve and, in turn, by resolving them, we are reducing the risks that they pose for other, related conditions.
Let us hope that, in the future, Nutrition and Hydration Week is a thing of the past because everyone, regardless of age or setting, has suitable and available good nutrition and hydration.