Nutrition and hydration in medical and preventive care for the elderly

Nutrition and hydration in curative and preventive care for the seniors The most articles were dedicated to nutrition and hydration in seniors with cognitive impairment and dementia (115 n.), with constipation (198 n.) and frail seniors (87 n.). By evaluating the questionnaire we found out that the hydration achieved an average score of 1.07, nutrition of 1.03. For focusing on individual interventions, the average score in the area was 2.85. In the area of ​​nutrition were 2.57. In the part of "Hydration", the nurses are focused on: education (1.18), frequent fluid administration (1.22). In the area of ​​providing nutrition, the nurses focus on: education (1.34), regular meals according to the regime of the institution (1.41) and diet therapy (1.61). Conclusion: Nutrition and Hydration are the main interventions of non-pharmacological treatment and it is still important to pay attention to them. Reserves are in interdisciplinary cooperation and in the application of nutrition and fluids enterally and parenterally. Key words: Nutrition. Hydration. Interdisciplinary Cooperation. Nursing interventions. Project KEGA

Nutrition and enough of all basic nutrients are extremely important for the human body. It is necessary to follow the principles of rational nutrition at any age, but old age is a particularly risky period (Čeledová, Čevela et al., 2017). Nutrition affects the overall state of the organism, physical and mental well-being, resistance to infections, accelerates wound healing, shortens the length of hospitalization and convalescence, and is part of the treatment of chronic diseases.

Conversely, insufficient nutrition reduces the body's resistance - it is the cause of increased morbidity and mortality in the elderly. It causes inactivity, increased fatigue, reduces muscle strength, there is a risk of thermoregulation disorders, wound healing and gastrointestinal (GIT) problems (Gadušová, 2017). It negatively affects the psyche and satisfaction of the social needs of the senior (Whitelock, 2018). The incidence of malnutrition increases with age, it is identified in 45% of seniors over the age of 75, immobile geriatric patients are particularly at risk, where up to 80% are malnourished (Hegyi, Krajčík, 2015). Hyponutrition is also diagnosed in oncologically ill seniors, frail seniors, after a stroke, seniors with Parkinson's and Alzheimer's disease. Depending on the place of residence, seniors in social service facilities (ZSS) are particularly at risk. According to research by Ondriová, Slaninková (2015), it can occur in up to 40% of the population. The highest incidence of malnutrition is in hospitals, where it is around 65% (Gadušová, 2017; Krajčík, Mikuš, Bajanová et al., 2018).

Adequate hydration and balance in the intake and output of fluids is also an important factor influencing the health status of an individual (Pokorná, 2013). On the contrary, insufficient intake, excessive consumption of fluids and subsequent dehydration represent a significant problem that affects the overall condition of the senior. Insufficient hydration is a frequent, serious phenomenon that is typical for seniors. It is a frequent cause of hospitalization. Clinical research by Dúbrav and Jánošiová (2014) identified that dehydration was the 5 most common cause of hospitalization. Dehydration reduces performance, appetite, causes disturbances in concentration, thermoregulation, headaches, drowsiness, increases irritability, body temperature, pulse rate. Long-term lack of fluids causes constipation, kidney function disorders, more frequent urinary tract infections and heart and blood vessel diseases (Schuler, Oster, 2010; Kalvach, 2008; Hegyi, Krajčík, 2015; Chen et al., 2016). Jurášková, (2003) states that with a loss of 1-5%, hypohydration is manifested by thirst, limitation of mobility, loss of hunger, fatigue, increased heart rate, increased temperature, nausea. A 6-10% loss causes dizziness, headache, breathing difficulties, tingling in the limbs, reduced blood volume, increased blood viscosity, cessation of saliva production, cyanosis, reduced articulation, balance disorders. With a loss of 11-20%, convulsions, swelling of the tongue, swallowing disorders, hearing loss, blurred vision, loss of skin sensitivity, anuria, delirium, cardiac arrest occur.

Based on the above facts, we can conclude that varied nutrition and hydration is the main geriatrician in old age (Zlatohlávek et al., 2016).

The application of rational or medical nutrition and the administration of fluids (per os, enteral, parenteral) belong to the daily treatment measures for hospitalized seniors, seniors in the home environment. The effect of the treatment is multiplied by the involvement and cooperation of the interdisciplinary team. The composition of the team members differs from the location of the seniors. In institutional facilities, doctors, nurses, practical nurses, nutritional therapists, physiotherapists, and family members often work together. In some specific cases, a speech therapist, dentist, occupational therapist, social worker. For seniors with more serious illnesses and nutritional disorders, the nutrition team coordinates and applies the optimal method of eating and hydration. In the Slovak Republic, its members are: doctor, pharmacist, geriatrician, nutrition assistant, ICU nurses, dietician, head transfusion physician (Vestník MZ SR 2009). In the home environment, a doctor, nurse, family members, carer, and social worker work together to ensure appropriate nutrition and the amount of fluids (Ondrušová, Matišáková, Drobná, 2014).

The most frequent interventions in the care of nutrition and hydration of seniors Nutrition care interventions

The identification of risk factors for nutritional disorders is most important in the care of nutrition for seniors in any place where the senior resides. Risk factors for the development of malnutrition are: weight loss, less than eight hearty meals per week, very little amount of vegetables and fruit, small amount of food consumed, long periods without eating or drinking during the day, depression and loneliness, three or more medications, immobility, more than two chronic diseases, acute illness, pressure ulcers, oral problems (Touhy, Jett, 2018). Risk factors for obesity are waist circumference, weight, inappropriate eating habits, accompanying diseases and syndromes - metabolic syndrome (dyslipidemia, hypertension, disorder of carbohydrate metabolism, hyperuricemia), CHD, previous vascular event, movement disorders, insufficient self-care, incontinence, steatosis of the liver (Krajčík, et al., 2017). Regular monitoring of the state of nutrition, control of food intake, education of seniors and family members, provision of an adequate form of food - rational nutrition, therapeutic nutrition (diet therapy), enteral and parenteral nutrition, cooperation and exchange of information with team members are also essential. For hospitalized seniors, it is important to evaluate the nutritional status before the senior is discharged.

Interventions in hydration care

The basic preventive and therapeutic interventions in the care of the hydration of the senior include the assessment of the current health and psychological state. We determine the occurrence of risk factors, medication, social and family anamnesis, previous occurrence of dehydration, physical examination and measurement of vital functions (condition of mucous membranes, skin turgor, occurrence of edema, density and color of urine, BP, P, TT, weight, height, BMI), laboratory tests (urea, creatinine), monitoring of fluid intake and output (Martinková, 2016).

Planned interventions in connection with ensuring hydration in seniors include:

• offer to drink at regular intervals, change liquids during the day, introduce rituals (e.g. regular meetings over tea) in long-term institutional care (Pokorná, 2013; Zanovitová, 2015), tie drinking liquids to regular daily activities, such as hygiene, brushing teeth, eating food, etc. (Krajčík, Mikuš, Bajanová et al., 2018),
• ensure good accessibility to liquids and enough aids to make them easier to take (a plastic cup with an ergonomic handle, a jug, or a bottle with marked times and levels...),
• for seniors at risk of hydration problems, regularly monitor oral hydration habits, urine color (Mentes, Kang, 2013),
• to provide suitable liquids in relation to diseases. Control the composition of mineral waters (higher sodium content, dangerous in hypertension and heart failure), increase the amount of fluids taken (3 liters) in case of urinary tract diseases, watch out for conversion in right-sided heart failure (1.5 liters),
• for mild dehydration caused by vomiting, diarrhea, administer oral rehydration solutions,
• in the case of the inability to receive fluids orally and the treatment of dehydration, apply them parenterally, enterally, or subcutaneously according to the doctor's office (Sláma et al. 2012). With established enteral nutrition, we apply liquids to the tube, they can be table and still mineral water, tea. In terminally ill patients, we administer fluids subcutaneously, it is the so-called hypodermoclysis. The infusion (F1/1, Glucose 5%) can be administered continuously 40-100 ml/hour, at night 60/120 ml/hour (Nemcová, 2013).

Application of nutrition and fluids for seniors in institutional facilities

In the previous text, we pointed out the importance of nutrition and hydration in the care of the elderly. By analyzing research, scientific papers, but also based on our own clinical experience, we can conclude that nutrition and fluid therapy is one of the main methods of non-pharmacological treatment of seniors. It is also an important part of the treatment of diseases and geriatric syndromes. Rational nutrition and an adequate drinking regime are key in maintaining the physical and mental condition of older people in the home environment and in ZSS. They contribute to the prevention of sarcopenia, falls, frailty, cognitive disorders... Through the research that was part of the KEGA project - Possibilities of interdisciplinary cooperation in the implementation of non-pharmacological treatment of seniors in institutional facilities, we wanted to confirm these facts.

The aim of the research was:

• to present a focus on intervention in the care of nutrition and hydration of seniors in institutional health and social facilities,
• find out for which diagnoses nutrition and fluid therapy is most often applied,
• find out how nurses satisfy the need for nutrition and hydration of seniors in institutional treatment,
• find out what are the real possibilities of interdisciplinary cooperation in institutional facilities.

Research methods and research file Research methods were narrative review and self-constructed questionnaire. The questionnaire was divided into two parts. The first part contained areas of non-pharmacological treatment. Respondents could mark the degree of importance of individual methods on a Likert scale. A 5-point Likert scale was used in the questionnaire. The number 1 meant the most important and the number 5 unimportant. The listed methods included nutrition, hydration and interdisciplinary cooperation. The second part was focused in detail on the interventions, and the respondents indicated on the Frequency scale how often they implement the interventions. Again, a 5-level Frequency scale was used. The number 1 meant always and 5 never.

Research file for narrative review consisted of professional, scientific articles, abstracts, research reports obtained from databases available in the University Library of the Catholic University in Ružomberok. The prerequisite for the selection was that the works were published in the period of the last 10 years - 2008-2018 and contained in the text information about nutrition, hydration, their application and importance in preventive and curative care for seniors.

The research set of the questionnaire method was 229 nurses from ZSS and medical facilities in Slovakia. The criterion for the selection of nurses was work in a facility that belongs to medical facilities providing care for seniors and ZSS. 130 were from ZSS and 99 from medical facilities (geriatric wards/clinics, remedial wards, treatment rooms/wards for long-term patients). The average length of practice of nurses was 18.82 years. 96 nurses had completed secondary education and specialization (nurses working in ZSS), 88 university education of the first degree and 45 university education of the second degree. degree.

Research Results

In the first mentioned method, based on entering keywords: nutrition in the treatment of seniors, hydration in the treatment of seniors, the importance of nutrition in seniors therapy, non-pharmacological treatment in seniors in studies searched in the databases Scopus, Web of Science, ProQuest Central, we obtained a set of documents that we subjected to analysis. After reviewing them and excluding inappropriate articles, research and abstracts, we found that nutrition and hydration is an important part of the complex treatment of seniors in community care and in institutional treatment. In nursing homes, nursing homes and boarding houses, the detection of nutritional disorders was one of the main preventive measures to maintain the good condition of seniors. Appropriate screening tools were also demonstrated. In institutional facilities, rehydration and therapeutic nutrition were part of the therapy of diseases. In Table 1, we list which diagnoses and syndromes it was most often used for.

Tab. 1 Nutrition and hydration in the therapy of seniors

By evaluating the questionnaire, we obtained information about the importance of nutrition, hydration and interdisciplinary cooperation in preventive and curative care for seniors in institutional facilities in the Slovak Republic, as well as about the frequency of implementation of individual methods. Table 2 shows the results from the first part of the questionnaire.

Tab. 2 Importance of selected non-pharmacological methods

The table shows that the nurses consider feeding, checking the drinking regime and hydration to be very important - both had an average score of 1. We achieved equally positive numbers when working with other professionals and the family.

In the second part of the questionnaire, we focused on interventions related to hydration and nutrition. For the "Hydration" area, there were 7 interventions: 1. education about the need for hydration, 2. frequent offering of fluids, 3. a cup within reach, 4. provision of favorite fluids, 5. serving foods with a higher H2O content, 6. serving solutions with increased electrolyte content, 7. intravenous application of solutions. Table 3 shows the results found.

Tab. 3 Frequency of implementation of the intervention for the area "Hydration"

The results of the table show that nurses most often educate the senior about the importance of hydration and compliance with the drinking regime, offering him fluids. They apply fluids intravenously less often - especially in ZSS. The worst score was the administration of solutions with an increased content of electrolytes - also especially for nurses working in the ZSS.

For the "Nutrition" area, 8 interventions were listed: 1. education about the importance of nutrition, 2. regular eating, 3. serving food according to the senior's taste, 4. diet according to the dietary regime, 5. diet adapted to the taste of the senior, 6. adjusting the consistency of the diet, 7. enteral application of diet - PEG, 8. parenteral nutrition. In Table 4, we can see how often the mentioned interventions are implemented by nurses.

Tab.4 Frequency of implementation of interventions for the field of "Nutrition"

Even when comparing the results of table 4, we can see that the most frequent intervention of the nurse is education, then it is serving food and diet according to the senior's taste. Adjustment of diet consistency and enteral and parenteral nutrition are implemented less often.

In the last evaluated area "Interdisciplinary cooperation", which we describe verbally, we found slight differences when comparing the results according to the nurses' workplace. Nurses from institutional health care most often collaborated with doctors and relatives. Nurses in ZSS most often cooperate with social workers and doctors, less often with relatives. In both types of facilities, they sometimes work with a nutritionist.

Discussion

The state of nutrition and hydration is one of the determinants affecting the self-sufficiency of seniors in acute and chronic care, but also in everyday life (Holmerová, 2014; Saghafi et al, 2018). Several scientific studies confirm that proper nutrition and lifestyle modification have a positive effect in the prevention or contribute to the stabilization of acute and chronic diseases (Touhy, Jett, 2018; Ivery et al, 2017; Kalhorzadeh, Shiralizadeh, Jabbarian, 2016). Unsuitable or insufficient nutrition, on the contrary, shortens life. An incorrect approach to nutrition can cause 60% of non-infectious and 70% of infectious diseases (Vidová, Lajdová, 2013). Inadequate nutrition increases the mortality of institutionalized seniors (Ondrušová, Matišáková, Drobná, 2014; Hoozová, Krajčík, 2015). Malnutrition affects 20-50% of patients in acute hospital wards and is associated with adverse clinical outcomes. Improper hydration is also a cause and consequence of the disease. Dehydration is associated with renal, urological, circulatory and respiratory problems and can result in increased mortality in the hospital (Kubešová, 2012). Despite these facts about the physiological and economic benefits of nutrition and hydration, they are often overlooked by health professionals in acute care hospitals (Whitelock, 2018). Many foreign and domestic studies offer the same findings. What is particularly alarming is the underestimation of hydration in the home environment and in the ZSS (Dúbrava, Jánošiová, 2014), failure of communication and information exchange between team members, insufficient recording of fluid balance in institutional facilities (Pokorná, 2013).

In our mixed research, we also aimed to find out the importance of nutrition and fluid therapy in acute and long-term care of seniors and in the treatment of which diseases it is used. Nutrition and hydration were most often an important part of the treatment of geriatric syndromes, neurological and psychiatric diseases. With the help of a questionnaire administered to nurses in institutional facilities in various regions of the Slovak Republic, we also obtained answers to other objectives. The positive data was that nurses consider nutrition and hydration to be important methods of non-pharmacological treatment in institutional care for the elderly, the average score was 1. After evaluating the second part of the questionnaire, however, we also found negative results similar to those in the presented studies. In both types of facilities, there were deficiencies in interdisciplinary cooperation, for example, cooperation with a nutritional therapist had an average score of 3. In most facilities, nutritional teams, which are very important especially in acute care, were absent. Another problem was the provision of enteral and parenteral nutrition in ZSS. Despite the fact that in the Slovak Republic, a nurse's competencies include: ... assessment of a person's state of health (including nutrition, hydration), application of nutrition - enteral, monitoring and assessment of fluid balance, application of parenteral nutrition based on a doctor's indication (Decree of the Ministry of Health of the Slovak Republic No. 95/2018 Z. z). The preparation and administration of the infusion and the feeding of the patient with a feeding tube are also included in the nine health services of nursing care in the ZSS (Appendix No. 7 to Act No. 577/2004 Coll.). In most ZSS, however, care is limited by material and technical equipment, the number of professional staff and the number of immobile patients. Even in our research, it was a relatively large number of 43%. The last negative finding was the score in the realization of education in ZSS. Education is also very important in old age, educating seniors about nutrition helps to improve their awareness and attitudes and causes changes and improvements in nutritional behavior, especially in long-term care (Kalhorzadeh, Shiralizadeh, Jabbarian, 2016). However, in our facilities, the number of nurses and the poor health and mental state of seniors were the limit.

Conclusion

Ensuring appropriate nutrition and hydration is the basis of comprehensive and high-quality care for seniors. However, this is only possible thanks to interdisciplinary cooperation and sufficient information about the current health, psychological and social condition of the senior. Therefore, early detection of at-risk seniors and problems in the field of nutrition and hydration is very important. Early detection of malnutrition and dehydration will make it possible to choose an appropriate treatment strategy for their elimination or removal, which leads to an improvement in the condition and general condition of the senior, satisfaction of family members, reduction of the burden on healthcare workers and, last but not least, savings in healthcare costs.

Authors: PhDr. Katarína Zrubáková, PhD., PhDr. Mária Novysedláková, PhD., PhDr. Eva Moraucíková, PhD., PhDr. Mariana Magerčiaková, PhD. Faculty of Health Sciences, University of Ružomberok References

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