Maintaining nutrition and hydration in care homes

Both how much and what you eat and drink not only affects your weight but it impacts on your mood, concentration levels and how you feel. In essence, ‘good’ food and hydration are essential for general wellbeing. So, as a healthcare worker, ensuring that your patients receive adequate amounts of nutrition and hydration is a fundamental aspect of holistic care.

Though this applies whatever clinical area you work in, it is particularly important when caring for elderly people in a care home setting. Here many residents will depend on you not only for the provision of meals and drinks, but also for assistance with eating and drinking.

Risk of malnutrition

The term ‘malnourished’ means that someone’s diet doesn’t contain the right balance of nutrients for the person to function properly. This can result in people losing weight (not enough nutrients) or gaining weight (too many nutrients). Sometimes people can even be the correct weight but still not have the right nutrients.

Weight loss isn’t the only sign of malnutrition. Other symptoms can include:

• Muscle weakness
• ­Feeling tired all the time
• ­Increased infections
• Increased accidents or falls
• ­Constipation
• ­Lack of energy
• ­Gaining weight
• ­Changes in behaviour
• ­Depression
• ­Poor wound healing

Malnutrition is a major concern for all care home staff as it can often happen gradually, e.g. weight loss happening over time can go unnoticed. Therefore, careful monitoring of dietary intake and regular weight measurements are vital in helping to keep older people happy and healthy.

Many older people are living with what’s called ‘co-morbidities’, i.e. they have more than one medical condition, e.g. diabetes, asthma and high blood pressure. When someone is malnourished, this will have a knock-on effect on all their conditions and overall wellbeing. Alarmingly, many elderly people who are admitted to hospital from a care home setting are at a risk of being malnourished or are already malnourished.

What you can do

Many of your residents will be frail and vulnerable. Though some may be able to eat and drink for themselves, they will still rely on you for providing meals and drinks. Other residents may require prompting to eat or drink and some may need full assistance. Therefore, you need to be aware not only of each resident’s care needs, but also of their likes and dislikes food-wise and be observant for any changes in their nutritional status (e.g. weight, skin, hair etc).

All of your residents should have ongoing assessments of their nutrition and hydration needs. Tools such as the Malnutrition Universal Screening Tool (MUST) can be helpful and should be kept updated. However, your assessment should also include allergies, likes and dislikes and any support the individual needs to eat and drink.

Well-nourished residents will have increased energy and will feel much stronger both physically and emotionally.

• There will be fewer calls to the local GP and a reduction in medication
• Fewer infections and colds
• Improved oral health
• Improved quality of life

All care home staff have a role to play in helping to ensure that residents don’t become malnourished.

Here are some tips:

Offer plenty of food choice

None of us want to eat the same food, day in day out. We all crave our favourite foods, but we also like to try new meals. So, care homes should provide a variety of different foods and allow residents to make their own choices. It is also important that care home residents have access to regular snacks throughout the day. Many older people do not want to eat three large meals a day, and instead prefer to graze regularly.

Balanced meals

In addition to offering a variety of foods, make sure that these cover the right quantities of all the main foods groups such as:

• ­ Fruit and vegetables
• ­ Bread, rice, potatoes, pasta and other starchy foods
• ­ Meat, fish, eggs, beans and other non-dairy sources of protein
• ­ Milk and dairy foods
• ­ Foods and drinks high in fat and/or sugar

More information on these can be found in the NHS’s Eat Well Guide.

Supervise meal times

As well as assisting residents during mealtimes according to their care needs, you can also use this time to assess each person, e.g. are they able to hold the cutlery? (conditions such as arthritis can make this hard). Some people may benefit from adapted cutlery or aids to help them eat independently.

For those residents who wear dentures it’s also worth observing if the person has any pain whilst eating as this could be a sign that the dentures no longer fit.

Care plans

Every resident should have a care plan specifically for their dietary needs, and if assistance is required. You can ask for help from occupational therapists to assess an individual’s needs for eating independently.

Monitor weights

Sometimes people will lose weight even if they are eating enough. Any unexpected weight loss needs further examination because of the risk of cancer and other health related issues. This is another reason to regularly monitor each individual’s weight.

Offer supplements

If a resident is reluctant to eat and they need to build up their weight, then one option is to give nutritional supplements. These must be prescribed, and you will need the input of a dietitian to ascertain the best type of supplement and to create a long term nutritional plan.

Supplements come in various forms, e.g. milky or fruity drinks, sauces and yogurts.

Hydration in care homes

Many care home residents do not drink enough fluids and often what is drunk is coffee and tea, both of which act as a diuretic (making someone go to the toilet more). Most residents don’t drink enough water. Over time, this gradual decline in drinking can lead to chronic dehydration, which in the elderly can be worrying.

Dehydration – the risk factors

Due to physiological changes as we age, older people are at a greater risk of dehydration. These risks are further heightened by changes to mental capacity and physical frailty. The elderly population are incredibly vulnerable to the consequences of not drinking enough fluids.

Changes due to the ageing process may mean that the older person has a reduced sensitivity to being thirsty – their brain does not register the fact that they need to have a drink. If they are not reminded to drink water regularly, then they can easily become dehydrated. Older people who have had a stroke or who have Alzheimer’s disease have this reduced sensitivity and need careful monitoring.

Other risk factors include declining renal function, cognitive impairment, and the regular taking of laxatives and diuretics.

Signs of dehydration

Common signs in the older person include:

• A dry mouth
• Sunken eyes
• Skin that’s lost its elasticity
• Drowsiness
• Disorientation or confusion
• Low blood pressure
• Feeling dizzy

One or more of these signs may be shown, along with reduced urine output.

Fluid balance

If you have concerns about a resident’s fluid intake, then it’s important that you monitor the input and output via a fluid balance chart. Not only will this indicate how much fluid is being drunk in a 24-hour period, but you can also monitor any other urinary problems.

Strategies to prevent dehydration

There are many ways that you can reduce the risk of dehydration in older people.

• Within the care home, staff need to give emotional support to reassure the older person that they can be assisted to go to the toilet. Staff also need to ensure that drinks are within easy reach and that the person can use the cup or beaker provided.
• Staff training must be ongoing and highlight the importance of adequate hydration. Each resident should have their own daily fluid goal and this goal should be met with the help of staff. Fluids should be regularly offered throughout the day, and water should be palatable and presentable. No one likes to drink lukewarm water.
• It’s also important that care staff are aware that many older people restrict their fluid intake because of the fear of incontinence, or night time urination. It is important that staff offer reassurance regarding these issues.

Ongoing training

Skills for Health provides eLearning for nurses and healthcare assistants on the topic of nutrition and hydration in the care home. Specific topics include those of assessing and using eating aids, diet management and fluid monitoring in the older person. If you are in need of additional training or would like to further your knowledge on this subject when caring for older people, then explore healthcare eLearning from Skills for Health.