Sugar and salt

Dr mabel Blades independent Freelance Dietitian and nutritionist

mabel is a Registered Dietitian, a member of the BDA and NAGe, Food counts and Freelance Dietitians Specialist Groups. All aspects of nutrition enthuse her and she is passionate about the provision of nutritional information to people to assist their understanding of any diet.

For full article references please email info@ networkhealth group.co.uk

SUGAR AND SAlT: AN ADDIcTIVe comBINATIoN?

With all of the attention being paid to sugar and salt reduction in the media coupled with a lack of understanding about the different types of sugar in food, dietitians are in a unique position to provide a sensible and balanced approach to both the media and their clients.

We eat food, of course, for various reasons, one of which is the flavour. The receptors of the ‘taste buds’ found on the tongue and soft surfaces in the mouth,1 detect the five different tastes of salt, sweet, sour, bitter and umami. Taste buds, except for those for salt, develop in the foetus during the first nine to 15 weeks of pregnancy and, thus, the foetus is exposed to flavours of the amniotic fluid which are derived from the mother’s diet. Strong foods, for example, like curry, will provide a strong flavour to the fluid.2 Babies are born with a love of sweet things which encourages them to take breast milk, but the taste buds for salt do not develop until about four months of age. Nevertheless, a study has indicated that babies exposed to salty foods at an early age develop a liking for it.3

salt (soDiUm chloriDe) It has long been realised that excess sodium in the diet is a major public health problem in the UK, clearly linking with hypertension and cardiovascular events such as coronary heart disease and strokes.4 In 2002, The Food Standards Agency launched a campaign to reduce salt in the estimated 26 million people in the UK who had a high dietary sodium intake. It was estimated at that time that a 3.0g/day reduction in salt could prevent 30,000 cardiovascular events and save the National Health Service at least £40million/year.5

. . . a study has indicated that babies exposed to salty foods at an early age develop a liking for it.

The recommendations for salt intake are well publicised by easily accessed information such as that on NHS Choices.6 The maximum levels of salt advocated are:

• 1 to 3 years - 2.0g salt a day (0.8g sodium) • 4 to 6 years - 3.0g salt a day (1.2g sodium) • 7 to 10 years - 5.0g salt a day (2.0g sodium) • 11 years and over – 6.0g salt a day (2.4g sodium)

In November 2014 Public Health England revealed that hypertension affects one in four people, plus accounts for 12% of all visits to GPs.7 The food industry has also taken great steps to reduce the salt content of processed

food products since the late 1980s and the Food and Drink Federation reports on initiatives due to a partnership between the food industry and the Food Standards Agency. Reductions in salt of 25% in sliced bread, 43% reductions in branded breakfast cereals, as well as reductions in other food items are detailed.8

Such reductions by the food industry have brought benefits and the latest information from Public Health England in March 2016 announced that there has been a reduction in salt consumption for adults to 8.0g per day, showing a downward trend over the last 10 years.9

Interestingly, there are also other sources of salt, such as effervescent tablets, including vitamins, which can contain as much as a gram of salt per tablet and such sources of salt can be overlooked.10

sUgar Much media attention has focused on sugar over the last year with newspaper headlines on the related health issues and the recommendation to cut sugar consumption by half. This was initially based on the advice of the World Health Organisation (WHO) to reduce free sugars to 5% of energy intake.11 The SACN report on carbohydrates also advised that only 5% of dietary energy should be taken from free sugars12 due to the following: • High levels of sugar consumption is associated with a greater risk of tooth decay. • The higher the proportion of sugar in the diet the greater the risk of a high energy intake. • Drinking high-sugar beverages results in weight gain and increases the BMI in teenagers and children. • Consuming too many high-sugar beverages increases the risk of developing Type 2 diabetes.

The previous recommendation on sugar was to limit non-milk extrinsic sugars (NME) to 10% of total energy intake.13. However, the population never managed to achieve this level with the average intake of non-milk extrinsic sugars (NMEs) for adults of 11% and for children up to 15%.14

Therefore, how likely are they to achieve a maximum of 5% energy from free sugars? In an article entitled Sugar Public Enemy No 1 (NHD Feb 2016 p12), Carrie Ruxton said that, “dietitians need to consider whether sugars are so detrimental to health that a monumental shift in eating patterns is justified”. This consideration of the suitability of such reductions was also spoken about by dietitian and nutritionist Azmina Govindji at a presentation on ‘Sugar - where are we heading?’ given at the SENSE meeting in London on 1st March 2016. Azmina also commented on the appropriateness of recommendations for the major reduction in sugar, as well as the fact that information on sugar from the SACN report had been the main focus, while the report also included advice to increase fibre intake which largely appears to have been neglected by the media.

Children, are already shown to have a high intake of NMEs, which includes a major contribution from the sugar in soft drinks. Thus, for this group, a reduction in the sugar content of the diet can be hugely beneficial and awareness items such as the ‘Sugar Swap’ app from Change4Life17 can provide information in an appropriate and helpful manner to such a technology aware group, enabling them to make early choices about how to reduce sugar in their food and drink.

In the 2016 March Budget, the Government introduced a sugar tax for soft drinks. There will be two bands of taxes, one for total sugar content

. . . awareness items such as the ‘Sugar Swap’ app from Change4Life can provide information in an appropriate and helpful manner . . . enabling them to make early choices about how to reduce sugar in their food and drink.

above five grams per 100 millilitres and a second higher band for the most sugary drinks with more than eight grams per 100 millilitres and this is due to come into force in 2018.15 The delay in introducing the sugar tax gives the industry time to respond in reformulating drinks.

Also in March 2016, the Eatwell plate was updated to the Eatwell Guide which gives clear information about foods and beverages containing sugar.16

For the general public there can be confusion about sugars and free sugars as food labels show total carbohydrate followed by the information on sugar without information about the nutritional benefits of the product. Thus, someone wishing to avoid sugar may mistakenly shun nutritious items such as fruit and milk due to the sugar content. Much clearer information is needed for the public based on appropriate food choices rather than constantly trying to interpret food labels.

Bliss Point The term ‘bliss point’ can be used by the food industry to adapt the amounts of three critical ingredients in a recipe - salt, sugar and fat - to deliver just the right amount of palatability to a foodstuff and to make the consumer want to eat more. To quote celebrity chef Nigella Lawson, “Ticking off the holy trinity of sugar, salt and fat - salted caramel is the class A drug of the confectionery world!”17

That combination of sugar, fat and salt is deeply alluring, perhaps evidenced by the fact that 12 million people watched TV’s Great British Bake off which encourages many to try home baking in which sugar is a key ingredient. Sugar is thought to activate the pleasure (dopamine) pathways in the brain which may result in it being addictive too. Some people require regular consumption of sugar and, indeed, sugar is even felt to be addictive by some people.18 But it is sugar and salt combined that gives maximum flavour and appeal evidenced by the everincreasing number of products on the market, such as salted caramel puddings and sweets, salted chocolate and salted sweet biscuits.

sUmmarY It is clear that humans are born with a liking for sugar and also an appetite for salt can occur later. Add to this the addictive quality of sugar, plus the desire for that bliss point in foods, as well as people being bombarded with various baking and cookery programmes, it is no wonder that people consume too much salt, sugar and fat with resultant consequences to health.

Advocating a drastic reduction of free sugar by both SACN and WHO to half the level which is already found to be a virtually non-achievable target may well result in simply an even wider gap of non-achievement. Fibre containing foods such as cereals may well require a little sugar to make them acceptable.

For the great majority of people, the limitation of free sugars is important to health, but it must be remembered that there are some individuals, such as older people with malnutrition, for whom sweet items are vital in encouraging them to eat. Some sports people rely on a diet higher in sugar to provide them with adequate calories to fuel the activity.

With all of the attention being paid to sugar reduction in the media, coupled with a lack of understanding about the different types of sugar in food, dietitians are in a unique position to provide a sensible and balanced approach to the inclusion of sugar and salt in the diet. Often, the whole discussion needs to be about portion sizes and dietary balance; as Mary Berry said in 2012, “Cakes are healthy too, you just eat a small slice”!

maeve hanan stroke specialist Dietitian, city hospitals sunderland, nhs

maeve works as a Stroke Specialist Dietitian in city Hospitals Sunderland. She also runs a blog called DieteticallySpeaking. com which promotes evidence-based nutrition and dispels misleading nutrition claims and fad diets.

THe Role oF VITAmIN D IN olDeR ADUlTS

Vitamin D is essential to our health, especially in relation to bone health. Older adults (generally defined as adults 65 years and older) have been identified as an ‘at risk’ group for vitamin D deficiency, but what are the current evidence-based recommendations for this population in terms of vitamin D?

Vitamin D plays a vital role in preventing rickets in children and osteomalacia in children and adults by promoting calcium absorption, bone growth and bone remodelling; it also maintains serum calcium and phosphate concentrations to support healthy bone mineralization.1,2 Vitamin D is also involved in: cell growth, genetic coding and functioning, neuromuscular functioning, immune functioning and reducing inflammation.3 There has been some inconclusive evidence which suggests an association between low vitamin D levels and diseases such as osteoporosis, diabetes, cardiovascular disease, tuberculosis, multiple sclerosis, preeclampsia and cancer.4

soUrces oF Vitamin D There are two main forms of vitamin D: vitamin D3 (cholecalciferol) and vitamin

Figure 1: Vitamin D metabolism pathway

table 1: Dietary sources of vitamin D

Food

Fish herring (grilled) salmon (farmed, grilled) salmon (farmed, steamed) salmon (pink, canned in brine, drained) salmon (cold & hot smoked) mackeral (grilled) mackeral (smoked) sardines (grilled) sardines (canned in brine, drained) tuna (baked) tuna (canned in brine, drained)

Mean vitamin D content (μg/ 100g)

16.1 7.8 9.3 13.6 8.9-11 8.5 8.2 5.1 3.3 3.1 1.1

eggs eggs (whole, boiled) eggs (yolk, boiled) meat Beef (rump steak, fried) 3.2 12.6

0.7

Fortified foods Bran flakes cornflakes rice cereal Fat spreads (reduced fat 62-75% polyunsaturated) 4.6 4.7 4.6 7.5

Taken from The Composition of Foods, 7th edition (Finglas et al, 2015) Source: SACN 2015 Draft Vitamin D and Health report: www.gov.uk/government/uploads/system/uploads/attachment_data/file/447402/Draft_SACN_ Vitamin_D_and_Health_Report.pdf

D2 (ergocalciferol). Vitamin D3 is synthesized from the action of ultraviolet B (UVB) rays with our skin; this is our main source of vitamin D and the reason it is often referred to as ‘The Sunshine Vitamin’. Vitamin D3 is also found in some dietary animal sources, such as oily fish, egg yolks and red meat. Vitamin D2 is found in plants and is formed via the action of UVB with the plant sterol ergosterol.4,5

The main circulating form of vitamin D is 25-hydroxyvitamin D [25(OH)D] which is produced in the liver.4 Conversion then occurs in the kidneys and the biologically active form of vitamin is produced, which is called calcitriol or 1,25-dihydroxyvitamin D [1,25(OH)2D].4

Vitamin D is added to certain foods such as fortified margarines and breakfast cereals (see Table 1) and can also be obtained from supplements, either in tablet form or from certain types of oral nutritional supplements (e.g. Ensure Plus Advance, Fortisip Extra, Nutriplen Protein etc).

Vitamin D reQUirements For aDUlts 65 Years anD olDer Previously, the Committee on Medical Aspects of Food and Nutrition Policy (COMA 1991/1998) only set dietary reference values for vitamin D for ‘at risk’ groups, such as pregnant women, breastfeeding women and adults over 65 years. However, based on evidence related to musculoskeletal health, the updated recommendations by the Scientific Advisory Panel on Nutrition (SACN) set the reference nutrient intake (RNI) for vitamin D at 10ug per day, as a ‘population protective’ level for the UK general population aged four and above; which includes those deemed ‘at risk’.4 SACN also defined serum levels of vitamin D (25(OH) D) as deficient when lower than 25nmol/L and sufficient when ranging from 50 to 125nmol/L.4 As vitamin D is fat soluble, excess intakes are stored in our body tissues. A guidance safe upper level for vitamin D of 25ug/day was set based on the risk of vitamin D toxicity which has been

Population group % with serum 25(OH)D below 25nmol/L (mean serum concentration)

19-64 years old 65 years and older men 19-64 years old men 65 years and older women 19-64 years old women 65 years and older men living in institutions women living in institutions 19-64 years old from January to march 65 years and older from January to march 19-64 years old from July to september 65 years and older from July to september 22.8% (45.4nmol/l) 21.0% (44.5nmol/l) 24.0% (43.5nmol/l) 16.9% (47.0nmol/l) 21.7% (47.3nmol/l) 24.1% (42.5nmol/l) 38% (33.7nmol/l) 37% (32.5nmol/l) 39.3% (34.8nmol/l) 29.3% (40.5nmol/l) 8.4% (57.5nmol/l) 3.6% (50.5nmol/l)

table 3: mean intakes of vitamin D for UK adults (adapted from nDns data)9

Population group

19-64 years old 65 years and older 19-64 years old including supplements 65 years and older including supplements men living in institutions men living in institutions including supplements women living in institutions women living in institutions including supplements

% mean intake of RNI (mean daily intake in μg)

28% (2.8µg) 33% (3.3µg) 36% (3.6µg) 51% (5.1µg) 38% (3.79µg) 39% (3.87µg) 33% (3.31µg) 34% (3.36µg)

associated with renal damage, cardiovascular damage and hypercalcaemia, which can lead to subsequent bone demineralisation.4 Although the evidence is less consistent, other reported adverse effects vitamin D toxicity include an increased incidence of falls and fractures, pancreatic and prostatic cancer and all-cause mortality.

Vitamin D leVels in UK aDUlts 65 Years anD olDer Many factors effect vitamin D exposure in the UK; for example, there is insufficient UVB light from mid-October to the beginning of April for cutaneous vitamin D synthesis, and minimal synthesis occurs outside of the time frame of 11am to 3pm due to UVB exposure levels.2,4,6 Other factors can contribute to low serum vitamin D levels, such as sun avoidance, sunscreen use, wearing concealing clothing, genetics, skin pigmentation, latitude, altitude, air pollution and cloud cover.4

It has also been suggested that the ability of the skin to produce vitamin D decreases with age; however, it is unclear whether this is related to confounding factors such as minimal sun exposure or possible co-morbidities such as impaired liver or kidney function.4

NICE and SACN highlight ‘adults 65 years and older’ and ‘frail and institutionalised people as specific ‘at risk’ categories for vitamin D deficiency.2,4

The UK National Diet and Nutrition Survey (NDNS), which ran from 2008 to 2009 and 2011 to 2012, found evidence of a high risk of vitamin D deficiency across all population groups which was substantially effected by seasonal variation (see Table 2 for adult data).7 It is interesting to note that this survey did not find a lower serum 25(OH)D concentration in adults 65 years and older compared to adults aged 19-64 years. The NDNS also found that those living in institutions, which are likely to include a large

Food group

% Contribution to vitamin D intake 19-64 years 65 years and older

meat and meat products 30% 23%

Fortified fat spreads

cereals and cereal products (from fortified breakfast cereals and baked goods using eggs and fortified fats as ingredients

Fish and fish dishes (mainly oily fish) 19%

13%

17% 19%

13%

23%

eggs and egg dishes

milk and milk products 13%

5% 13%

6%

Vegetables and potatoes 1% 0%

proportion of older adults, had significantly higher levels of vitamin D deficiency than the general population. adults, but fish and fish dishes contributed a higher intake for adults age 65 years and older (see Table 4).

Vitamin D intaKes in the UK aDUlts 65 Years anD olDer The NDNS reported intakes below the RNI for vitamin D across all adult groups, it also found that adults 65 years and older had higher mean intakes of vitamin D than adults aged 19 to 64, both from food sources alone and food sources in combination with supplements (see Table 3). According to this data, supplements seemed to contribute more to serum vitamin D levels for adults 65 years and older than those aged 19 to 64.7

As it is very difficult to achieve the RNI for vitamin D from dietary sources alone, in 2012 the UK Chief Medical Officers advised that, “people aged 65 years and over and people who are not exposed to much sun should take a daily supplement containing 10 micrograms of vitamin D”.8 As a follow on from this, due to evidence that a large proportion of the UK population are at risk of vitamin D deficiency, SACN have recommended that consideration be given to ‘strategies for the UK population to achieve the RNI of 10µg/d for those aged four years and older’.4

The individual food groups contributing to vitamin D intake were found to be quite similar across all adult age groups; however, ‘meat and meat products’ contributed a higher intake for adults aged 19 to 64 years than with older

Vitamin D anD health oUtcomes in an aDUlts 65 Years anD olDer Although the evidence is mixed, SACN report that there appears to be a benefit to vitamin D supplementation in adults over 50 years in relation to falls risk, muscle strength and muscle function. However, there was evidence of an increased falls risk in one randomised control trial when an annual high dose of vitamin D (12,500µg/500,000 IU) was administered.4

From the available evidence SACN conclude that low serum vitamin D levels (ranging from 4-20nmol/L) are associated with a higher incidence of osteomalacia in adults of all age groups; which suggests a benefit to vitamin D in this regard.4 However, this evidence is based on mainly cross sectional studies and case reports. In adults over 50 years old, current meta-analysis evidence reports a small benefit of vitamin D supplementation in improving femoral neck bone mineral density; however, there was no benefit with bone mineral density in the spine or total hip found.4

Overall, vitamin D supplements have not been found to be beneficial in regard to fracture prevention in adults over 50 years; however, the evidence is conflicting and suggests that vitamin D, along with calcium, is more effective than vitamin D alone.4 SACN also found a possible protective effect of vitamin D supplementation

on all-cause mortality; especially when used in combination with calcium supplementation.4

Currently, there is not enough strong evidence to support an association with vitamin D and cancer, CVD, autoimmune diseases, oral health, psychological conditions, infectious diseases, or age-related macular degeneration.

conclUsion Vitamin D plays a clear role in musculoskeletal health; with recent evidence reporting a specific benefit of vitamin D supplementation for older adults helping to reduce falls and the risk of osteomalacia and also improving muscle strength and function.

As previous guidelines only address ‘at risk’ groups, an updated practical guideline for healthcare professionals to use in relation to advising vitamin D supplementation in adults would be useful for clinical practice; as recent research highlights a high risk of vitamin D deficiency across all adult population groups in the UK.

As vitamin D deficiency can have a big impact on a person’s nutritional status and overall quality of life, this should be an important consideration as part of nutritional assessments and management plans. Correcting vitamin D deficiency is likely to become increasingly relevant to dietitians with the introduction of independent prescribing.

References 1 NIH Vitamin D Factsheet for Health Professional: https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ 2 NICE guideline PH56, Vitamin D: increasing supplement use in at-risk groups: www.nice.org.uk/guidance/ph56 3 Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010 4 SACN 2015. Draft Vitamin D and Health report:www.gov.uk/government/uploads/system/uploads/attachment_data/file/447402/Draft_SACN_Vitamin_D_ and_Health_Report.pdf 5 SACN 2007. Update on Vitamin D: www.gov.uk/government/uploads/system/uploads/attachment_data/file/339349/SACN_Update_on_Vitamin_D_2007.pdf 6 NHS Choices - How to Get Vitamin D From Sunlight: www.nhs.uk/Livewell/Summerhealth/Pages/vitamin-D-sunlight.aspx 7 National Diet and Nutrition Survey: results from Years 1 to 4 (combined) of the rolling programme for 2008 and 2009 to 2011 and 2012: www.gov.uk/ government/statistics/national-diet-and-nutrition-survey-results-from-years-1-to-4-combined-of-the-rolling-programme-for-2008-and-2009-to-2011-and2012 8 Vitamin D - advice on supplements for at risk groups - letter from UK Chief Medical Officers: www.gov.uk/government/publications/vitamin-d-advice-onsupplements-for-at-risk-groups 9 Appendix 2, Chapter 8 Dietary vitamin D intakes and plasma 25 hydroxyvitamin D concentration of the UK population tables: www.gov.uk/government/ uploads/system/uploads/attachment_data/file/447405/Appendix_2_-_Chapter_8_NDNS_intake_tables_.pdf

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anne wright registered Dietitian, am Dietetics

Anne has extensive experience in many areas of Dietetics including clinical roles whilst working in Australia as well as with the NHS in Higher education. Anne is now a freelance practitioner with Am Dietetics

For full article references please email info@ networkhealth group.co.uk

DYING FoR A DRINK: DeHYDRATIoN IN ReSIDeNTIAl AGeD cARe FAcIlITIeS

Following sensational newspaper reports on the ‘scandal of dehydrated elderly rushed to hospital’ from residential aged care facilities (RACF) in England1 and with the release of the NHS England document 2015-2018 Guidance - commissioning excellent nutrition and hydration, 2 last year, the spotlight has been placed very firmly on residential aged care facilities (RACF) and hydration.

Dehydration is defined 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 resulting from limited fluid intake, and is reflected in raised osmolality.2

Dehydration in elderly people is particularly problematic and can lead to poor health outcomes such as constipation, poor oral hygiene, increased rate of infection, falls, medication toxicity and more frequent hospitalisation. Dehydration in older people is preventable and can have a significant impact on quality of life. Many frail older people are not drinking sufficient fluid to maintain adequate hydration. As a result, the risk of dehydration is increased in residents living in aged care facilities.3 In a recent UK study4 involving 21,610 subjects, it was found that the odds of dehydration being diagnosed at hospital admission from RACF were 10 times greater than in elderly subjects being admitted to hospital from their own homes. Residents in RACF with dementia, diabetes and kidney problems are at most risk of dehydration.5

Although inadequate hydration, along with malnutrition, is one of the most longstanding and pressing problems in nursing homes, there is little research on the prevalence either of borderline or overt dehydration.6 The current scope of dehydration in RACF in the United Kingdom is unknown, however, one recent study conducted in a single NHS Trust in 2015 found that one in five residents was clinically dehydrated.5

at risK elDerlY 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.7 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.8 Some current guidelines suggest a minimum of 1,500ml of fluid daily for an older person.3

Elderly people are more at risk of suffering from dehydration for a number of reasons. These vary depending on each case. Age-related changes and problems put older people at increased risk of not drinking sufficient fluid to meet their daily requirements. With age, body water content decreases and with this decrease, the body becomes more susceptible to dehydration from the loss of a small amount of body water. There is also less renal mass with age, reflecting glomerular sclerosis and glomerular loss, with a consequent reduced ability to control the balance of both sodium and water, resulting in an increased incidence of dehydration.9

Fluid losses through diarrhoea, vomiting, diuretics, fever, sweating, heat and humidity can also contribute.

table 1: early signs of dehydration

Dry mouth thirst confusion headaches

Darker urine reduced urinary output hypotension and dizziness

Falls weakness

Urinary tract infections cramps

Dry skin and loss of skin recoil time irritability

Fever malaise constipation

Limitations in oral intake can be due to reduced thirst sensation, dysphagia, (requiring modified fluids or food), reluctance to drink to manage incontinence, reduced cognition, poor mobility and reduced functional capacity, limited access to fluids and reliance on staff to assist with oral intake. Residents who must be fed are at particularly high risk. Medications and polypharmacy can also contribute to dehydration risk.

Early recognition of dehydration is a priority and the key to a speedy recovery. Mild to moderate dehydration in elderly people can be easily missed. Often dehydration is not diagnosed in the elderly until they are admitted to hospital.5

In the older adult, dehydration often causes atypical symptoms which contribute to delayed recognition. Early (or mild to moderate) signs include dry mouth, thirst, confusion, headaches, darker urine, reduced urinary output, hypotension and dizziness, falls, weakness, fatigue, urinary tract infections, cramps, dry skin and loss of skin recoil time, fever, irritability, malaise and constipation. Confusion, constipation and falls are part of the very frequently occurring ‘geriatric giants’ and, therefore, their specificity as a single parameter is far too low to be useful in diagnosing dehydration.10 Classical signs of dehydration such as loss of skin recoil time, increased thirst and orthostatic hypotension, have a low sensitivity in older adults (60-75%).11

table 2: consequences of dehydration in residents increased hospitalisation increased mortality constipation reduced cognition function

Falls

Poor wound healing

Utis hyperthermia orthostatic hypotension

DeaDlY conseQUences Dehydration in the elderly can result in poor health outcomes. If not identified and treated, the health consequences are significant, even life-threatening. Several studies support that dehydration is associated with increased mortality rates among hospitalised older adults.3 In older adults with multiple comorbidities, dehydration can lead to more frequent hospitalisations.12 Dehydration can also result in comorbidities including urinary tract infections, constipation, impaired cognitive function, falling, orthostatic hypotension and poor wound healing.13

Over half of all nursing home residents are thought to be affected by urinary incontinence. 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.14 Reduced urine flow from inadequate fluid intake is one factor that puts the older person at greater risk of developing urinary tract infections.

Constipation is common in the long-term care setting because of limitations on patient mobility and food and fluid consumption.15 Constipation can be an indication of functional dehydration, an issue for elderly patients whose food and fluid consumption tends to be limited and for those who limit fluid intake to control urinary incontinence.

Hydration status and cognitive function in the elderly is an area which warrants more research. In healthy adults, being dehydrated by just 2% impairs performance in tasks that require attention, psychomotor and immediate memory and working memory tasks, as well as assessment of the subjective state.9 In the

elderly, dehydration has been associated with cognitive problems (i.e. confusion and impaired cognition).6

Falls can be associated with dehydration associated with resulting confusion and disorientation and/or postural hypotension. Dehydration has been identified as a causative factor in fragility factors.16

Dehydration renders elderly skin vulnerable to infection or wounding resulting from trauma. Dehydrated skin is less elastic, more fragile and more susceptible to breakdown. Dehydration can also contribute to delayed wound healing due to poor oxygen perfusion, essential nutrients not being delivered to the wound surface and draining inefficiency.

It has been shown that rehydration, has demonstrated a beneficial effect on conditions such as poor wound healing and hypotension.17

aDDressing the ProBlem oF DehYDration Prevention is key when managing dehydration in RACF. Adequate screening and training programs should be in place to assist early identification. Practical strategies should also be employed in RACF to ensure hydration targets are met.

The NHS England document 2015-2018 Guidance - commissioning excellent nutrition and hydration,2 recommends a strategy for commissioners for tackling the nutrition and hydration needs of the population which includes developing quality frameworks to support provider organisations in putting nutrition and hydration at the heart of care.

The reference (or gold) standard measurement for hydration is serum osmolality, assessed using blood samples.14 This method is considered invasive and costly. Dehydration in older people could be accurately identified as part of routine blood testing, according to a study from the University of East Anglia (UEA).5 Results from this study suggest that routine blood tests for sodium, potassium, urea and glucose could be used to screen for dehydration by putting the results of these tests through an ‘osmolarity equation’. Current screening for dehydration in RACF remains largely observational. RACF staff should be familiar with the recommendations outlined in the Francis report (2013),18 which highlights the need for proper records to be kept of the food and drink supplied and consumed by older patients. Residents should be routinely monitored for signs of dehydration. A fluid balance chart should be started for all patients who are acutely unwell or considered at risk of dehydration.

Development of hydration policies in individual RACFs is a crucial component of interventions to prevent dehydration. These policies should be put in place with accompanying education and awareness programs for staff, residents and families.

Strategies which may be employed to reduce dehydration risk include: • Offer and encourage water and preferred fluids at each mealtime. • When giving medicines, give with slightly larger volumes of water (or use standardised amounts). • Encourage small sips through the day; individual pre-measured fluid targets can be useful. • Provide hot drinks and consider drink variety (e.g. water and lemon), for residents who prefer hot drinks. • Encourage morning fluid consumption for residents who are afraid of late night toilet visits. • Use fluid intake tools - electronic and paper based records. • Educate care givers and family regarding the importance of hydration. • Ensure functional issues are catered for - e.g. glasses not too heavy, adapted cups, straws Provide physical assistance as needed - adequate staffing levels and time allocated to achieve this. • Provide drinks during group and social activities. • Encourage recognition and communication of dehydration symptoms. Adequate hydration for residents in RACF should be considered a safeguarding issue. Ensuring adequate hydration for the elderly requires the involvement of the entire interdisciplinary team. The dietitian not only has a key role in developing malnutrition screening tools, local policies and education, but also in doing so for hydration in RACF.

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