WATER FOR
WELLBEING
A resource kit to promote adequate
fluid intake for the older person
VCRC
VICTORIAN CONTINENCE RESOURCE CENTRE
ACKNOWLEDGMENTS
The Victorian Continence Resource Centre
(VCRC) is a not-for-profit organisation that aims
to promote continence for all people living in
Victoria. We are the Continence Foundation of
Australia Victoria Branch, the peak body for
bladder and bowel health. Our aim is to raise
awareness about bladder and bowel control
problems, management and treatment options,
and where to get help. The VCRC reaches out to a
wide demographic that is ethnically, gender, age,
socio economically diverse through a range of
educational activities and events.
The assistance of representatives of the following
organisations, who formed the original project
advisory group and provided input to the concepts
and development of the materials is greatly
acknowledged: Cabrini Residential Care Ashwood,
City of Banyule, Department of Human Services
Aged Care Branch, Doutta Gala Community
Health Service, Royal District Nursing Service and
St.Georges Hospital. Excerpts from the ‘Water
for Healthy Ageing: Hydration Best Practice for
Care Homes’ toolkit are reproduced with the kind
permission of Water UK.
This resource kit has been developed to assist
Home and Community Care Providers (HACC) and
Residential Aged Care Facilities (care managers,
health professionals, assessment staff, care
workers and informal carers). The aim of the kit
is to promote the benefits of adequate fluid intake
for frail older people and to develop hydration
practice that is evidence informed. The work has
been led by the Victorian Continence Resource
Centre, Continence Foundation of Australia
Victoria Branch.
In this 2nd edition, we would like to acknowledge
the ongoing support and contributions of Amanda
Kingham, Cabrini Residential Care Ashwood; Sue
van Buuren, Salford Park Community Village; and
Martin Knapp, Renal Physician.
2 ACKNOWLEDGEMENTS
WATER FOR WELLBEING
CONTENTS
Introduction 4
About the resource kit
5
About water and the body
6
How fluid is lost from the body
6
Recommended fluid intake for the older person
6
Health benefits of adequate fluid intake
6
8
Signs of dehydration
9
Why the older person is at risk of dehydration
9
Water myths and facts
Dehydration 10
Strategies on how to encourage adequate fluid intake
12
Monitoring hydration status and fluid intake
14
Recommendations for hydration
15
References 16
Appendix 18
3 CONTENTS
WATER FOR WELLBEING
4 INTRODUCTION
WATER FOR WELLBEING
INTRODUCTION
Drinking adequate amounts of fluid is essential
for health and wellbeing.
ABOUT THE RESOURCE KIT
Almost every bodily function requires water:
breathing, digestion and absorption of nutrients,
waste removal and temperature control are just a
few examples of how the body uses water.
Water for Wellbeing offers a range of resources,
written for the older person, care workers,
informal carers and health service providers. We
encourage you to read all the material within the
kit and identify those resources that best suit your
care setting. You may wish to mix and match the
tools in other combinations to the ones we have
suggested. We in fact hope you will find more
creative ways of using the tools to enable good
hydration practice in your care setting.
Many frail older people are not drinking sufficient
fluid to maintain adequate hydration. As a result,
dehydration is common in older adults living in
residential care facilities and those living in the
community.
The consequence of not drinking sufficient
fluid can lead to poor health outcomes such as
constipation, poor oral hygiene, urinary tract
infections, and may be a factor in hospitalisation.
These health problems are often perceived as
minor issues but for the individual, dehydration
can have a significant impact on their quality of
life.
The purpose of the Water for Wellbeing resource
kit is to provide community and residential
aged care services with tools to assist the
implementation of hydration practice that is,
where possible, evidence-informed thus improving
health outcomes and quality of life for clients and
residents.
In this second edition, we have revised and updated
the evidence base, with only some minor changes.
Consequently, the tools have been revised and the
number of tools have been reduced to create a
more user-friendly and practical resource.
Throughout the kit we use the terms water and
fluid interchangeably. This is done deliberately as
water is the preferred drink and all other fluids are
at least 80% water (Popkin, D’Anci and Rosenberg
2010). We make recommendations on the types
of fluids that can be offered freely and those that
should be limited.
ABOUT WATER AND
Important: the kit is a general guide only and may not be suitable for individuals on fluid restrictions
due to specific health problems and illnesses.
5 INTRODUCTION
WATER FOR WELLBEING
ABOUT WATER AND THE BODY
On average, our bodies are 60% water and it is
the primary component of all bodily fluids - blood,
lymph, digestive juices, urine, tears and sweat
(Tortora and Derrickson 2010). Water is critical
to many bodily functions - circulation, digestion,
absorption and the elimination of wastes to name
a few. Water carries electrolytes (mineral salts)
that help convey electrical currents in the body;
the major elements that make up these salts are
sodium, potassium, calcium and magnesium.
Water is one of the six nutrients vital for life; the
others being carbohydrates, proteins, minerals,
vitamins and lipids.
HOW FLUID IS LOST FROM
THE BODY
All persons breath, sweat, pass urine and faeces.
The fluid lost, known as obligatory loss, must be
replaced to maintain the water content in the body.
On average a person loses around 2.5 litres of fluid
each day. An inactive older person’s fluid loss may
be closer to 2 litres per day. Fluid is lost in the
following ways (Tortora and Derrickson 2010):
Breathing 300 mL
Sweating
600 mL
Urine output 1500 mL
Faeces
100 mL
Physical activity and a hot environment further
increases the amounts of fluid loss, through an
increased breathing rate and excessive sweating.
In residential aged care, the ambient temperature
6 ABOUT WATER AND THE BODY
is around 25°C, thus loss from sweating will be
similar for residents throughout the year. It is also
important to remember to maintain fluid intake in
the colder months. If an individual has diarrhoea or
vomiting then fluid loss will also increase.
RECOMMENDED FLUID INTAKE
FOR THE OLDER PERSON
Adequate intake of ‘total water’ comes from
the combined intake from drinking water, other
beverages and food sources. Approximately 60%
of total water intake comes from fluids, 30%
comes from moist foods and the remaining 10%
is produced by the body’s metabolism (Tortora
and Derrickson 2010). Optimal daily fluid intake
depends on various factors including weight,
health status and energy expenditure, therefore;
there is no single recommended daily intake (RDI)
for adults (Godfrey et al 2012).
The current guidelines suggest a minimum of
1500ml of fluid daily for an older person (Mentes
2006).
HEALTH BENEFITS OF ADEQUATE
FLUID INTAKE
To maintain health everyone needs to drink well
and maintain fluid balance. Fluid balance meaning
that fluid intake equals output (Mentes 2006).
Some of the health benefits of adequate fluid
intake and problems of inadequate fluid intake for
the older person are summarised below.
WATER FOR WELLBEING
Bladder health: Maintaining adequate fluid intake
is important for the health of the bladder. Many
older people limit their fluid intake in an attempt
to prevent urinary incontinence or the need to go
to the toilet overnight, known as nocturia. This
strategy has little or no effect on these bladder
symptoms and may worsen for some individuals
(Gray and Krissovich 2003; Townsend et al 2011).
Urinary tract infections (UTIs) are common in
residential aged care. Reduced urine flow from
inadequate fluid intake is one factor that puts the
older person at greater risk of developing UTIs.
Adequate fluid intake is therefore an important
strategy in reducing UTIs in residential aged care
(Ruxton 2012; Whitehead 2009).
Bowel health: Adequate fluid intake is one
simple measure that reduces any tendency for
‘dehydrated’ hard stools and constipation. In
conjunction with dietary fibre, adequate fluid intake
can increase stool frequency and improve stool
consistency, making bowel motions easier for the
older person (Ruxton 2012).
Blood pressure: Many older people upon sitting
or standing, experience lowered blood pressure
(postural hypotension) which may cause a fall and
loss of consciousness. Lu et al (2003) suggests
drinking a glass of water before sitting or standing
helps to prevent this change in blood pressure and
reduces the risk of fainting. There are many other
causes of postural hypotension, these include
blood pressure medications, diuretic therapy,
diabetic neuropathy and adrenal dysfunction.
7 ABOUT WATER AND THE BODY
Cognitive function: Cognitive function
progressively deteriorates as the level of
dehydration increases. Common symptoms of mild
dehydration include headache, irritability, poor
concentration and reduced alertness (Wilson and
Morley 2003; Rogers, Kainth and Smit 2001). Once
thirst is felt cognitive performance may be affected
by up to 10% (Rogers, Kainth and Smit 2001). In
an older person this loss of cognitive function
impacts on any existing functional impairments
and increases their levels of dependency, reducing
their quality of life (Wilson and Morley 2003).
Skin and tissues: Well hydrated skin and tissue
is more resilient to tears and to the effects of
pressure, thus reduces the risk of pressure ulcers
(Little 2012; Ruxton 2012). Good hydration may also
improve healing (Benelam and Wyness 2010).
Falls prevention: Older people have an increased
risk of falls. Tzeng and Yin (2012) found that
dehydration was one of the major preventable risk
factors for falls in acute care settings.
The cognitive changes (poor concentration and
reduced alertness) and lower blood pressure
(fainting and feeling dizzy) increases the person’s
risk of a fall (Mentes and Culp 2003).
WATER FOR WELLBEING
DEHYDRATION
8 DEHYDRATION
WATER FOR WELLBEING
Many frail older people living in residential aged
care and also those living within the community
do not maintain a fluid intake adequate to avoid
dehydration (Bennet, Thomas and Riegel 2004;
Shimizu et al 2012).
Dehydration results when more fluid is lost from
the body than is taken in. The consequence of
not drinking sufficient fluid can cause rapid
deterioration in the health of the older person,
resulting in hospitalisation. However, the majority of
frail older people drink just enough fluid to prevent
acute dehydration but not sufficient to meet all their
body’s needs (Bennett, Thomas and Riegel 2004).
SIGNS OF DEHYDRATION
In the absence of a clinical definition for
dehydration, the most accepted definition is the
‘rapid weight loss of greater than 3% body weight’.
Other definitions state dehydration as a water
and/or electrolyte imbalance, either with water
depletion only or with sodium depletion with an
associated loss of water (Hodgkinson, Evans and
Wood 2003).
Detectable clinical and physical signs of dehydration
include appearance of a dry tongue and mucous
membranes, sunken eyes, poor cognition, speech
difficulty, confusion, upper body muscle weakness,
raised body temperature, low fluid intake, dry
armpits and palms, slow capillary refill, low
urine volume and usually dark or concentrated
urine. These signs have the strongest correlation
with dehydration. The severity of dehydration is
determined by biochemical markers (Hooper et al
2013; Hodgkinson, Evans and Wood 2003).
Sequential biochemical markers have an important
role in monitoring for possible dehydration
and in any assessment. The relevant markers
often performed as part of ‘routine’ monitoring
are plasma urea/creatinine ratio and serum
osmolality, sodium and tonicity (Hooper et al 2013).
Other measurements including urine concentration
such as specific gravity may be needed for
diagnosis and management when dehydration is
suspected.
At one end of the scale, mild dehydration may cause
someone to feel only a little thirsty. At the other end,
severe dehydration can result in death.
9 DEHYDRATION
WHY THE OLDER PERSON IS AT
RISK OF DEHYDRATION
Older people have similar fluid requirements to
those of younger adults. However, some age related
changes and problems put older people at increased
risk of not drinking sufficient fluid to meet their daily
requirements.
Thirst signal and appetite: The body is provided with
a thirst signal to indicate when we need to drink
more fluid. Most people drink sufficient water or
other fluids and so infrequently feel thirsty.
In older people, the thirst signal is often impaired,
so they do not feel the sensation to drink (Scales
2011). As a result, older people will often refuse
drinks when they are dehydrated because they do
not feel thirsty. Furthermore, a diminished appetite
or poor nutrition may result in the older person not
eating or drinking adequately.
Social setting: Many of our social interactions
revolve around eating and drinking. For some older
people either living along or having moved into
a residential care facility, their life routines have
significantly changed. Opportunities to have a cup of
tea with friends or family may no longer be a prompt
to have a drink. In addition, some people have never
developed good drinking habits and resist the offers
of fluid particularly if they do not have a good thirst
mechanism.
Health problems: A number of health problems
put older people at risk of dehydration and some
examples are listed below:
Dementia - the person may forget to drink or not be
able to interpret the thirst sensation.
Neurological disorders - such as Parkinson’s
disease, stroke and Motor Neurone disease may
result in the person having difficulties in swallowing
or impair their ability to get fluids independently.
Incontinence or poor bladder control – many people
with bladder problems reduce their fluid intake
hoping to minimise episodes of incontinence and
reduce the number of trips to the toilet, especially at
night.
Increasing frailty - everyday tasks become more
difficult with increased age, resulting in greater
dependence on others for assistance with drinking
and eating.
WATER FOR WELLBEING
WATER MYTHS AND FACTS
10 WATER MYTHS AND FACTS
WATER FOR WELLBEING
MYTH DRINK EIGHT GLASSES OF WATER
EACH DAY
MYTH B
Y THE TIME YOU GET THIRSTY,
FACT T here is no clear benefit from drinking this
FACT T he body’s thirst signal sets in well before
amount of water each day and the origin
of this claim is not based on research
evidence (Rush 2013). Of the 2 to 3 litres
of water a day your body needs, about one
litre is obtained from the food we eat, and
your body produces another 250mL when
it metabolises the food. This leaves about
1.25-1.75 litres to actually drink. This is
equal to about six cups, each 250mL.
More importantly, this fluid can be obtained
from a number of sources, not just water.
MYTH IF YOU HAVE A BLADDER CONTROL
PROBLEM, DRINKING LESS WATER
HELPS
FACT P
eople who have bladder control problems
often reduce their fluid intake so they
don’t need to go to the toilet as often.
However, less fluid intake has the effect of
concentrating the urine, which can irritate
the bladder causing more frequent visits to
the toilet.
MYTH O
LDER PEOPLE ARE AT GREAT RISK
OF OVERHYDRATION
FACT Whilst some older people are on fluid
restrictions due to specific health conditions
such as congestive heart failure or renal
disease, the risk of dehydration is greater
for the majority of older people and is far
more common.
MYTH TEA AND COFFEE HAVE A DIURETIC
EFFECT SO DON’T COUNT TOWARDS
DAILY FLUID INTAKE
FACT There is still debate on whether caffeine,
found in tea, coffee and some carbonated
soft drinks have a diuretic effect. A recent
review suggests that caffeine has a mild
diuretic effect and may increase urine
output; however, the fluid consumed in
the beverage counteracts this short-term
effect and contributes towards fluid intake
(Benelam and Wyness 2010).
11
WATER MYTHS AND FACTS
YOU ARE ALREADY DEHYDRATED
the threshold for dehydration. However,
the sensitivity to this signal decreases with
age, so that if an older person is thirsty,
they may already be dehydrated.
MYTH IF YOUR URINE IS DARK, YOU’RE
DEHYDRATED
FACT Urine colour alone does not signal
dehydration. If less urine volume is also
present and/or desire to urinate is less than
twice a day, then dehydration is possible.
Some medications, vitamins and foods are
also known to alter the colour of urine.
MYTH BOTTLED WATER IS BETTER THAN
TAP WATER
FACT N
ot necessarily. Australia has access to
some of the safest, best quality tap water
which adheres to guidelines set by the
National Health and Medical Research
Council. A Choice (2013) article found that
bottled water costs almost 2000 times
more than tap water, with no health
benefits. If poor tasting tap water is an
issue, consider using a filter cartridge
to help modify taste.
MYTH DRINKING LOTS OF WATER HELPS CLEAR
OUT TOXINS FROM THE BODY
FACT A
key function of the kidneys is to remove
waste and excess material in urine. Kidney
function, namely filtration, is not enhanced
by a greater water intake. Kidney filtration
is reduced in severe dehydration.
MYTH DRINKING EXTRA WATER LEADS TO
WEIGHT LOSS
FACT T here is some evidence that water
consumed before or during a meal does
promote satiety or feeling ‘full’ and slightly
increases energy expenditure, however, due
to a lack of good-quality studies, further
research is required (Muckelbauer et al
2013).
WATER FOR WELLBEING
STRATEGIES ON HOW TO ENCOURAGE
ADEQUATE FLUID INTAKE
In residential aged care, it has been estimated that
a third of residents are dehydrated (Mentes and
Wang 2010). In conjunction with existing practices,
the following research-based strategies may be
effective in increasing and maintaining adequate
fluid intake among older people.
FLUID INTAKE PATTERNS
Older people should be offered drinks and
encouraged to drink regularly throughout the day.
Taking small sips often assists fluid absorption
by the body rather than drinking large amounts
at once (Schols et al 2009). Furthermore,
overhydration can result from consuming very
large quantities of fluid if the older person has
a diminished ability to excrete water as seen in
severe cardiac, liver or renal failure. (Benelam and
Wyness 2010; Heneghan et al 2012).
In residential care, staff should offer or encourage
the older person to drink fluid during meals,
with snacks and regularly in between meals.
Daily activities such as brushing teeth, taking
medication, during social activities and therapy are
key opportunities to encourage fluid consumption
(Schols et al 2009; Godfrey et al 2012).
For people with an overactive bladder, urge
incontinence or severe cognitive impairment, fluid
limitations two hours before sleep and ensuring a
trip to the toilet before bedtime can be considered
(Stewart 2010).
12 STRATEGIES ON HOW TO ENCOURAGE ADEQUATE FLUID INTAKE
SUPPORTIVE ENVIRONMENT
As people age, physical and cognitive function
declines, which may result in the need for
assistance to drink fluid. It is important to create
a supportive environment for drinking by making
older people comfortable, placing drinks within
reach, pouring out their drinks, placing the drinks
in their hands and using drinking aids when
required. For older people that are unable to ask
for a drink, regular offerings throughout the day
may be a simple solution (Godfrey et al 2012).
Godfrey et al (2012) highlights the importance
of making drinking a pleasurable experience by
encouraging staff and relatives to sit with the older
person, engage in a conversation and have a drink
with the person.
TYPES OF FLUID
Preferred drinks
Older people should be encouraged to drink water as
well as being provided with their preferred drinks. This
has been shown to increase fluid intake (Simmons,
Alessi and Schnelle 2001). Certain drinks, such as
tea and coffee, may trigger fond memories and be
associated with socialising with friends and family.
Godfrey et al (2012) suggests that in conjunction
with a supportive environment, the presentation of
appealing drinks should promote enjoyment and
respect the dignity of the older person. This includes
not only offering a person’s preferred drink, but also
the preferred temperature of the fluid and type of drink
vessel (Hooper et al 2013).
WATER FOR WELLBEING
Caffeine
Thickened fluids
There are often claims made about the diuretic
effects of caffeine, which is thought to cause a loss
of fluid from the body as a result of a stimulation
urine output. As mentioned, in the myths and
facts section of this resource, a recent review
suggests that caffeine has a mild diuretic effect
and may increase urine output. However, the fluid
consumed in the beverage counteracts this shortterm effect (Benelam and Wyness 2010). Also,
the link between high caffeine intake and urinary
incontinence remains controversial as studies have
found either no association or limited association
(Karon 2009).
For older people that have swallowing difficulties
(dysphagia), the use of fluid thickeners can assist
with fluid intake. When using thickened fluids,
care needs to be taken when preparing the correct
viscosity. Fluid entering the lungs (aspiration) may
result if fluids are too thin. Fluids that are too thick
may cause a person to choke or deliver less water
than the measured volume, increasing the risk of
dehydration. Staff training in the preparation and
administration of thickened fluids is recommended
(Hines et al 2010).
In the case of the older person who habitually
drinks tea and coffee, these fluids should not be
restricted, as it may lead to dehydration. However,
tea and coffee should not provide the only source of
fluid intake.
Alcohol
Alcohol has a diuretic effect; however water and
alcohol content is variable depending on the type of
alcoholic beverage consumed. A standard drink of
beer will have more water and less alcohol than a
standard drink of wine and even more so than in a
standard drink of spirits. Without additional fluids,
alcoholic drinks may cause dehydration and should
be limited (Benelam and Wyness 2010; Schols et al
2009). The National Health and Medical Research
Council recommends no more than two standard
drinks a day for men and women.
13 STRATEGIES ON HOW TO ENCOURAGE ADEQUATE FLUID INTAKE
Oral hydration supplements
Further research is required to determine the
effectiveness of oral hydration supplements.
In one study, hydration was found to have been
significantly improved when an oral hydration
solution was supplied to supplement fluid intake
up to the client’s pre-determined total fluid
goal. The study was however, not randomised
or controlled and included a small number of
experimental subjects (Hodgkinson, Evans and
Wood 2001).
WATER FOR WELLBEING
MONITORING HYDRATION STATUS
AND FLUID INTAKE
Individuals should be screened and monitored for
hydration problems. General monitoring should
include any signs or symptoms of dehydration,
the onset of complications, and the impact of
treatments including any undesired effects of
treatments. Monitoring of vital signs, general
strength, function and cognition should be
conducted.
If an individual is determined to be at risk of
dehydration, monitoring fluid intake and urine
output should be performed. This is usually only
feasible or needed for short-term fluid monitoring
and for people in whom acute changes in fluid
balance are clinically important. Daily weighing
using accurate scales is another method of
monitoring fluid balance (Scales 2011). This can be
followed with further laboratory assessments for
dehydration to confirm a diagnosis (Ruxton 2012).
However, there are medications, vitamins and
foods which change urine colour and urine passed
when dehydrated can still be pale (e.g. urine
passed with high outputs of sugar is usually pale).
Also, incontinence pads which are commonly used
in aged care makes it difficult to assess urine
colour. Decisions about fluid status based just on
urine colour may be incorrect for several reasons
but the interpretation of colour change in urine
may be a useful alert to a need for more fluid
intake or to investigate further.
The best results are obtained in older adults
with adequate renal function once the effect of
discolouration by food and medications has been
ruled out. This method is most effective when the
average urine colour baseline is calculated over
several days (Mentes, Wakefield and Culp 2006).
A dehydration risk appraisal checklist (DRAC)
can also be used to identify individuals at risk of
dehydration (see appendix for checklist).
URINE COLOUR
Urine colour has been promoted as an effective
method for monitoring fluid intake. Urine that is
plentiful, odourless and pale in colour (pale straw)
generally indicates that a person is well hydrated.
Dark (like apple juice), strong-smelling urine in
small amounts could be a sign of dehydration.
14 MONITORING HYDRATION STATUS AND FLUID INTAKE
WATER FOR WELLBEING
RECOMMENDATIONS FOR HYDRATION
The following are recommendations for improving adequate fluid intake among the older person for use in residential aged care and HACC:
1 Frail older people should drink at least 1500mL of fluid a day, unless advised otherwise by
their doctor
2
Provide or encourage small amounts of fluid to be taken consistently throughout the day
3
Offer fluids at 1.5 hourly intervals to bedridden residents through the day
4
Offer preferred fluids
5 Caffeinated beverages (e.g. tea and coffee) are a source of fluid and can be counted towards
the daily fluid intake goal. Tea and coffee should not be the only source of fluid intake
6 Alcoholic beverages should be limited to no more than two standards drinks a day for men
and women
7 Identify and monitor at risk individuals; fully dependent for dehydration and semi-dependent for
adequate fluid intake
8
Monitor fluid intake and or output
9
Educate carers and older people on the volumes of containers to serve fluids
romote fluid intake at the beginning and end of organised activities and also during
10 P
the activity
15 RECOMMENDATIONS FOR HYDRATION
WATER FOR WELLBEING
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WATER FOR WELLBEING
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dehydration. Nursing Older People 23 (5): 16-22.
Schols, J., C. De Groot, T. Van Der Cammen, and
M. Olde Rikkert. 2009. Preventing and treating
dehydration in the elderly during periods of illness
and warm weather. The Journal of Nutrition,
Health & Ageing 13 (2): 150-6.
Shepherd, A. 2011. Measuring and managing fluid
balance. Nursing Times 107 (28): 12-6.
17 REFERENCES
Shimizu, M., K. Kinoshita, K. Hattori, Y. Ota,
T. Kanai, H. Kobayashi, and Y. Tokuda. 2012.
Physical signs of dehydration in the elderly.
International Medicine 51: 1207-10.
Simmons, S., A. Alessi, and J. Schnelle. 2001.
An intervention to increase fluid intake in nursing
home residents: prompting and preference
compliance. The Journal of the American Geriatrics
Society 49(7): 926-33.
Stewart, E. 2010. Treating urinary incontinence
in older women. British Journal of Community
Nursing 15(11): 526-32.
Tortora, G., and B. Derrickson. 2010. Introduction
to the human body: the essentials of anatomy and
physiology. 8th ed. New York: John Wiley & Sons.
Townsend, M., Y. Jura, G. Curhan, N. Resnick, and
F. Grodstein. 2011. Fluid intake and risk of stress, urgency, and mixed urinary incontinence. American
Journal of Obstetrics & Gynecology 205 (1): 1-10.
Tzeng. H, and C. Yin. 2012. Frequently observed
risk factors for fall-related injuries and effective
preventive interventions. Journal of Nursing Care
Quality 28(2): 130-8.
Whitehead, E. 2009. NVQ explained, part 9:
managing continence issues. Nursing &
Residential Care 11 (5): 224-8.
Wilson, M., and J. Morley. 2003. Impaired cognitive
function and mental performance in mild dehydration.
European Journal of Clinical Nutrition 57 (2): S24-9.
WATER FOR WELLBEING
APPENDIX
The following is a brief summary of the resources to be found on the CD-ROM which is included in the kit.
These resources are available in pdf format. Note some of these resources are only available electronically
on the CD and not included in the printed booklet.
You will need Adobe Acrobat Reader installed in your computer to download and view these files.
This program can be obtained free at the following web address: www.adobe.com.
Standard 2.10 Nutrition and Hydration Recommendations for Hydration
Category: Education tools for staff and older people
Water for Wellbeing:
a guide to fluid intake
Water and your body
Ways fluid is lost from the body
Water is vital for your body’s health.
Almost every function in the body requires water:
On average we lose around 2.5 litres of fluid each
day. Aninactiveolderpersonmaylosecloserto2
litresoffluidperday.
• Breathing
• Digestionandabsorption
• Wasteremoval
• Temperaturecontrol
Water for wellbeing: a guide to
fluid intake
A brochure for older people and
carers, explaining the benefits of
drinking enough fluids and a guide to
how much and what to drink
Fluids and the older person:
factsheet
A factsheet for carers of older people
explaining the benefits
of and tips for encouraging
adequate fluid intake
Exercisingandhotweatherincreasestheamount
offluidslost.Themoreactiveyouarethemoreyou
needtoincreaseyourfluidintake.
• Bloodcirculation
Rememberitsalsoimportanttomaintainyourfluid
intakeinthewintermonths.
Watermakesupabout60%ofthebodywhichhas
nostoragefacilities.Freshsuppliesofwaterare
requiredeachday.
How much fluid is enough?
Wemustreplacetheamountoffluidlostorwewill
endupdehydrated.
Health benefits of drinking well
Drinking well helps to:
• Reducetheeffectsofoveractivebladder,suchas
fre-quencyandurgencytopassurine.Restricting
yourfluidscanirritatethebladderfurtherby
concentratingtheurine
• PreventUTIs
Foodprovidesabout1litreoffluidreplacement.
Mostfruitandvegetablesare70-80percentwater.
Mostfoodssuchasicecream,custard,soups,
yoghurtandjelliesaremainlywater.Evenfoods
wethinkofasdrysuchasbread,haveagoodproportionofwater.
But we still need to drink an additional 1500mL of
fluid to match the fluid loss from day to day living,
unless advised oth-erwise by your doctor.
• Preventconstipation
• Maintainbloodpressure
• Keepyourmindworkingwellbyimproving
concentration,memoryandalertness
• Hydratetheskin,whichinturnmakesaperson
lesspronetodamagefromknocksandbumps
• Preventfalls
• Keepthemouthmoistandhealthy
VCRC
For further information contact (03) 9816 8266 1300 220 871
[email protected] www.continencevictoria.org.au
©ContinenceFoundationofAustraliaVictoriaBranchInc.SupportedbyfundingfromtheCommonwealth
andVictorianGovernments
VCRC
VICTORIAN CONTINENCE RESOURCE CENTRE
Water for Wellbeing:
fluids and the older person
VICTORIAN CONTINENCE RESOURCE CENTRE
• Fluidisourtransportsysteminthe
body,takingnutrientstothecellsand
removingwaste
Why are fluids important?
OUR BODIES ARE APPROX
FLUID
• Itsoftensbowelactions,makingthem
easiertopass
60%
• Fluidshelptomaintainbodytemperature
• E
achdaywelosefluidthroughbreathing,
sweating,urineproductionandinbowel
motions
Fluids – the good and the bad
• Fluidscomeinmanyforms;water,icypoles,fruitjuice,milk,tea,
coffeeandcordial.Manyfoodsaremainlyfluids(custard,jelly,
icecream,yoghurt,fruitandsoup)andtheseallcontributetothe
requireddailyintake.
• T
eaandcoffeeareagoodsourceoffluidbutbecauseitcontainscaffeine,
itshouldnotbetheonlyfluidapersondrinks.
• A
lcoholshouldbelimitedasithasadiureticeffectthatcausesexcess
fluidlossfromthebody.Extrawaterisrequiredtoreplacethefluidloss
causedbyalcoholconsumption.
How much is enough?
Some symptoms of mild dehydration are:
• Mostofusknowthatweshoulddrinkat
least1500mLoffluideachday.Manyfrail
olderpeoplearenotdrinkingenoughfluid
tomaintainadequatehydrationandmeet
theirdailybodilyneeds.
• Poorconcentration
• Irritability
• Headaches
• Fatigue
• Someolderpeoplemaybeonfluid
restrictionsduetospecifichealth
conditions.Itisadvisedtocheckwiththeir
doctor,whocanestablishadailyfluidgoal
fortheindividual.
• Increasedconfusion
• Faints&falls
For further information contact (03) 9816 8266 | 1300 220 871
[email protected] | www.continencevictoria.org.au
©ContinenceFoundationofAustraliaVictoriaBranchInc.
Water for wellbeing: urinary tract A brochure for older people and
infections
carers, explaining the signs and
symptoms of UTIs and their prevention
Urinary
Tract Infections
The risk of developing a urinary tract infection (UTI)
increases as we get older. Women in particular are
more prone to recurrent UTIs.
Urinary tract infections:
• Affect the bladder and/or kidneys
• Risk increases with age
• Are more common in middle aged and older
women
Why the older person is at risk?
Normal age related changes lower body defence
mechanisms
• Poor fluid intake
• Constipation
• Reduced mobility
• Incontinence
Common signs and symptoms:
• Incontinence aides, especially catheters
• A frequent urge to pass urine
Costs & carer burden associated with UTIs
• Difficulty in passing urine
• A burning sensation when passing urine
• Urine may be cloudy or have a strong smell
• Lower back or abdominal pain are sometimes
experienced
• Behaviour changes
The costs of UTIs are significant for older people and
their carers. Costs include:
• Poor health outcomes for the older person
• Increased carer workload
• Increased treatment costs
• Increased care costs
VCRC
For further information contact (03) 9816 8266 1300 220 871
[email protected] www.continencevictoria.org.au
© Continence Foundation of Australia Victoria Branch Inc. Supported by funding from the Commonwealth
and Victorian Governments
VICTORIAN CONTINENCE RESOURCE CENTRE
Practical tips for
encouraging water
consumption
1
Start by encouraging your team to develop a
policy on how residents will receive adequate
hydration. Refer to standard 2.10 Nutrition and
hydration.
2
A positive approach often helps to encourage
older people to drink more fluids. For example,
phrases such as ‘Here is some nice cool
refreshing water for you’ is more productive
than ‘Do you want something to drink?’
3
An ideal time to offer water is when giving older
people their medications.
4
Always provide a glass of water alongside
coffee, tea or alcohol.
5 Older people often worry about increased toilet
visits overnight. To avoid this problem, distribute
1500mL fluids evenly throughout the day to
reduce the number of late evening drinks.
Practical tips for encouraging
water consumption
A factsheet for carers with more tips to
encourage older people to drink more
water
Frequently asked questions
(FAQs)
FAQs for carers
Hydration awareness quiz for
staff
Multiple choice questions for staff
professional development
9 Hot water with a piece of fruit such as lemon,
lime or orange, can appeal to those who want
a hot drink.
10 Introduce older people to a variety of herbal teas
as an alternative to plain water.
11 As the weather gets warmer encourage and
remind older people to drink more. Perspiration
increases in warmer weather. Extra fluids may
need to be offered overnight.
12 Offer and encourage fluids during a meal times.
Make sure that older people who are less able
are assisted to drink.
13 Use a symbol such as a water drop near those
who are at specific risk and need their water
intake monitored. Make sure staff are aware of
the symbol and its meaning.
6 Older people can lose their thirst response and
taste sensation. Never assume that they know
when to drink.
7 Where possible inform family and friends about
the importance of promoting hydration.
8 For day trips and for use in outside areas,
providing a personal water bottle can help. These
are easy to carry, to clean and to refill, and can
be marked clearly with the person’s name.
VCRC
For further information contact (03) 9816 8266 1300 220 871
[email protected] www.continencevictoria.org.au
© Continence Foundation of Australia Victoria Branch Inc. Supported by funding from the Commonwealth
and Victorian Governments
VICTORIAN CONTINENCE RESOURCE CENTRE
Frequently asked
questions (FAQs)
VCRC
VICTORIAN CONTINENCE RESOURCE CENTRE
Q1. How can I get an older person to enjoy
and ask for water?
• Presentation of tap water is important to help
increase consumption.
• Assist the older person to make improved healthy
choices by helping them to understand the benefits
(see the Practical tips for encouraging water
consumption fact sheet).
Q2. How should I offer tap water to make it
taste as good as possible?
Q4. Is tap water safe to drink?
• Yes. The mains tap water supply in most urban and
regional areas is safe to drink and of high quality.
• Always make sure that the tap water you are
providing is fresh from the mains and not from
stored water tanks, where possible.
• If in doubt about the water quality in your building,
always check with your local water company first,
particularly in drought affected areas.
Q5. Do I need to filter or treat tap water before I offer it to drink?
• Taste tests have shown that tap water is enjoyed
when it is provided fresh and cool (not too cold and
not warm).
• No. The tap water is carefully monitored and tested
and is supplied ready to drink straight from the tap.
• Improve the taste of plain water by adding a
flavoured ice cube, fresh mint or a slice of fruit.
This lifts the visual as well as taste sensation.
• Sometimes filters will polish the taste slightly,
but the same effect can normally be achieved by
leaving the water to stand.
• Tap water provided from water coolers becomes a
feature, and allows water to be offered chilled or at
room temperature.
• Adding a little ice or chilling the water in the fridge
will help take away any chlorine taste.
• If offering cordials, make sure they are well diluted,
fortified (eg with vitamin C) and sugar-free.
Q6. How much water should an older person
drink?
Q3. What can I do if an older person
insists on drinking mostly hot drinks?
• Guidelines for adequate fluid intake among the frail
older person suggest a minimum of 1500 mL of
fluid per day.
• That’s fine as long as they are drinking plenty of
appropriate fluids.
• What we do know is that most people, especially
older people, drink nowhere near that amount, and
mild dehydration is very common.
• Promoting hot water with pieces of fruit in it
works well.
• Try and avoid strong caffeinated drinks and offer
caffeine-free as an alternative.
• It is vital to encourage older people (and staff) to
drink more.
For further information contact (03) 9816 8266 | 1300 220 871
[email protected] | www.continencevictoria.org.au
© Continence Foundation of Australia Victoria Branch Inc.
VCRC
Hydration awareness
quiz for staff
VICTORIAN CONTINENCE RESOURCE CENTRE
Photocopy this sheet and tick off your answers.
Correct answers are given over the page.
1. What is the chemical name for
drinking water?
H20
5. Which drink would be best to drink to protect
your teeth and gums?
Fizzy cola
C3PO
Coffee
He3
Water
2. How much minimum fluid should the frail
older person drink each day for good health?
2 litres
1500mL
2.5 litres
3. Approximately how much of your body is
made up of water?
60%
6. How should you drink your daily water
intake?
All at once
Regular sips
Big mouthfuls
7. How much water does simply breathing in and
out use up each day?
A pint (600mL)
40%
A glass (250mL)
15%
A bathful
4. How long can you live without water?
About one week
About one month
About one year
8. How much water on average is removed from
the body daily as urine from the bladder?
250mL
400–500mL
1 litre
1.5 litres
For further information contact (03) 9816 8266 | 1300 220 871
[email protected] | www.continencevictoria.org.au
© Continence Foundation of Australia Victoria Branch Inc. Supported by funding from the Commonwealth and Victorian Governments
18 APPENDIX
WATER FOR WELLBEING
Poster
Are you drinking
enough water?
Awareness raising poster
Keep your system flushing well,
drink at least 1500mL of fluid a day
Make water your first choice
VCRC
Call 1300 220 871 for further information
or visit www.continencevictoria.org.au
VICTORIAN CONTINENCE RESOURCE CENTRE
Category: Care provision tools for staff
VCRC
Management strategies for different
types of fluid intake problems
VICTORIAN CONTINENCE RESOURCE CENTRE
CAN DRINK
CAN’T DRINK
Functionally capable of accessing
and consuming fluids but may not
know what is adequate intake or
may forget to drink
Those who are physically incapable
of accessing or safely consuming
fluids related to physical frailty or
difficulty swallowing
INDepeNDeNT
FORgeTs
sWAllOWINg
DIFFICulTIes
• Frequent offers
• Educate; how much
WON’T DRINK
physICAlly
DepeNDeNT
• Use measuring cup
• Fluid during activities
• Swallowing exercises
• Sports cup with straw
• Provide preferred
beverages
• Tea time/happy hours
• Foods rich in fluid,
smoothies
• Physical aids to assist
with drinking
• Beverage cart
Those who are capable of consuming
fluids safely but who do not because
of concerns about being able to
reach the toilet with or without
assistance or relate they have never
consumed many fluids
FeARs
INCONTINeNCe
• Educate about
maintaining fluid intake
• Pelvic floor exercises,
urge inhibition
• Oral care
Management strategies for
different types of fluid intake
problems
Chart for carers outlining the different
types of fluid intake problems of older
people and suggested management
strategies to use in addressing these
Am I hydrated? Urine Colour
Chart
Chart for carers and older people to
use in monitoring hydration status
My Daily Fluid Intake Record
Chart for HACC carers and clients to
use to monitor fluid intake
Dehydration risk appraisal
checklist
Checklist for residential care nursing
staff/carers to identify residents at risk
sIppeR
• Sports cup with straw
• Physical aids to assist
with drinking
• Medication as a last
resort
• Educate family to help
Source: Mentes, J. 2006. A typology of oral hydration: problems exhibited by frail nursing home residents. Journal of Gerontological Nursing 32 (1): 13-27
For further information contact (03) 9816 8266 | 1300 220 871
[email protected] | www.continencevictoria.org.au
© Continence Foundation of Australia Victoria Branch Inc. Supported by funding from the Commonwealth and Victorian Governments
Am I hydrated?
Urine Colour Chart
VCRC
VICTORIAN CONTINENCE RESOURCE CENTRE
Use this simple urine colour chart to assess if you are drinking enough fluids throughout the day
to stay hydrated. Match the colour of your urine sample to a colour on the chart.
1
1 to 3 = HydrAted
2
This is ideal
3
4
4 to 6 = MIldly deHydrAted
Start to increase your fluids
5
6
7
7 or 8 = deHydrAted
Drink more fluid
8
Note: Use of a urine colour chart is suggested for people
with adequate renal function and not by people who wear
incontinence pads.
Best results are obtained when the average urine colour
baseline is calculated over several days.
The colours you see on this chart should only be used
as a guide.
Reference: Armstrong. L., J. Soto, F. Hacker, D. Casa, S.
Kavouiras, and C. Maresh. 1998. Urinary indices during
dehydration, exercise, and rehydration. International
Journal of Sport & Nutrition 8: 345-55.
Urine that is plentiful, odourless and pale in colour
(pale straw) generally indicates that a person is well
hydrated.
Dark, strong-smelling urine, (like the colour of apple
juice), in small amounts could be a sign of dehydration.
Certain foods, medications and vitamin supplements
may cause the colour of urine to change even though
you are hydrated.
For further information contact (03) 9816 8266 | 1300 220 871
[email protected] | www.continencevictoria.org.au
© Continence Foundation of Australia Victoria Branch Inc. Supported by funding from the Commonwealth and Victorian Governments
My Daily Fluid
intake Record
VCRC
VICTORIAN CONTINENCE RESOURCE CENTRE
Tick a drink below when each drink is finished. Try to have the most number of ticks in the ‘drink most’ category.
Make water your first choice. Tea, coffee, cordial, milk and fruit juice are good sources of fluid too, but should not be the only
drinks you have. Alcohol and soft drinks should be limited.
DRink Most
DRink in MoDeRation
DRink less
The recommended minimum daily fluid intake for older people is 1500mL (6 cups) per day.
(Unless advised by the doctor)
aRe you DRinking enough?
For further information contact (03) 9816 8266 | 1300 220 871
[email protected] | www.continencevictoria.org.au
© Continence Foundation of Australia Victoria Branch Inc. Supported by funding from the Commonwealth and Victorian Governments
Dehydration risk
appraisal checklist
A dehydration risk appraisal checklist (DRAC) can be used to identify individuals at risk of dehydration.
The total number of risk factors should be totalled. The higher the number of risk factors checked, the
higher the risk of dehydration.
DehyDration risk appraisal checklist
significant health conditions
checklist
MMSE * score <24 (indicating cognitive impairment)
Urinary incontinence
Dementia diagnosis
GDS * score >6 (indicating depression)
Semi-dependent in ADLs *
Repeated infections
History of dehydration
intake behaviours
checklist
Abnormal body mass index
Can drink independently but forgets
Has difficulty swallowing
Requires assistance to drink
Poor eater
Medications
checklist
Laxatives agents
Psychotropic agents
Diuretic agents
*ADLs = activities of daily living; GDS = Geriatric Depression Scale; MMSE = Mini-Mental State Examination
Source: Mentes,J., and J.Wang.2010. Measuring risk for dehydration in nursing home residents. Research in Gerontological Nursing 4 (2): 148-56.
For further information contact (03) 9816 8266 | 1300 220 871
[email protected] | www.continencevictoria.org.au
© Continence Foundation of Australia Victoria Branch Inc. Supported by funding from the Commonwealth and Victorian Governments
19
APPENDIX
WATER FOR WELLBEING
VCRC
VICTORIAN CONTINENCE RESOURCE CENTRE
Continence Foundation of Australia Victorian Branch
P: (03) 9816 8266
F: (03) 9853 9727
Advice Line: 1300 220 871
E: [email protected]
www.continencevictoria.org.au