How Much Do Elders Drink? Elders at home drink a greater variety and amount of fluids than those elders residing in institutions.

FLORA ADAMS

For nurses involved in direct care of the institutionalized elderly, one of the most basic responsibilities is to provide residents with food and fluid. Too often, this activity can be frustrating and time consuming. "I just can't get him or her to drink," is a

Flora Adams, RN, BSN, MSN, is a nursing in- structor at Skagit Valley College, Mount Ver- non. WA.

comment frequently heard in nurs- ing homes, and nurses at times feel guilty that residents are not getting adequate fluids.

With this in mind and after re- viewing research on physiological changes, characteristics, and nutri- tion of institutionalized elderly, questions emerged about the fluid in- take practices of this group. To an- swer these questions, a study was de- signed to describe and compare the fluid intake practices of the institu- tionalized and noninstitutionalized elderly in relation to time pattern, amount, and type of fluid intake.

First, i twas determined that sev- eral conditions affect the fluid intake of institutionalized elderly. Because of limited mobility and inconti- nence, many nursing home residents

may voluntarily reduce fluid intake in order to decrease their embarrass- ment at having to ask too frequently for nursing assistance(I).

Often when fluids are "available" to patients, no intake actually occurs. Immobility may prevent clients from reaching pitchers and water glasses routinely left at patients' bed- sides between meals.

Confusion, present in a number of institutionalized elderly, also con- tributes to a decrease in fluid intake, placing the immobile, confused client at risk of dehydration(2). In two studies, the dehydrated condi- tion of several immobile nursing home residents with lowered levels of consciousness was attributed to possible nursing neglect(3,4).

In addition to the reduced func-

218 Geriatric Nursing July/August 1988

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tional ability of institutionalized el- derly to obtain fluids, there are age- related physiological changes(5). The specific age-related changes that di- rectly affect fluid intake involve a de- crease in the renal function of regula- tion of urine output and a decrease in thirst(6,7). The cumulative effect of aging, immobility, and confusion, therefore, is to raise the potential for dehydration(3).

McConnell, who examined the ef- fect of specific nursing interventions on urinary tract infection in institu- tionalized elderly, provided impor- tant information on their oral fluid intake(1). The sample consisted of 102 residents age 60 to 100 residing in a comprehensive care facility. One nursing intervention was encourag- ing fluids. A total of 1,400 ml offluids per day was offered with meals. While data were not reported regard- ing the actual oral fluid intake of sub- jects, it was reported that residents said that the staff were trying to "float them away"(l).

Hart and Adamek attempted to demonstrate a reduction of renal cal- culi in 28 nursing home patients who had Foley catheters by having nurses encourage subjects to increase their fluid intake to a minimum of 2,000 ml per day(8). Only 31 percent drank this amount; the average fluid intake did not exceed 1,600 ml per day. It was reported that the elderly subjects

generally did not like to drink water. Hart and Adamek stated it may be unrealistic for nurses to expect the elderly to consume 2,000 ml of fluids daily(8).

What amount of fluid intake should elders drink? Fluid and food intake and metabolism supply daily

Residents may reduce their fluid intake to avoid asking too often for nursing assistance.

water intake. Recommended water intake amounts vary according to en- ergy requirements. The standard amount of daily water intake (water and other beverages) for a nonper- spiring adult weighing 70 kg is about 1,500 ml(9). Since no differing norms were identified for the elderly as a group, 1,500 ml per 24 hours could be considered an amount for compari- son purposes.

Research Study

In this study, it was predicted that there would be a significant differ- ence in amount, time pattern, and type of fluids between institutional-

ized and noninstitutionalized elder- ly. In addition, the amount of daily fluid intake for each group was to be compared with the average daily re- quirement of 1,500 ml.

The convenience sample com- prised 30 institutionalized and 30 noninstitutionalized elderly sub- jects, ranging in age from 65 to 85 years old. All were screened to ex- clude those with cognitive impair- ment, major disabilities, and those with diabetes mellitus because of the possibility of it affecting their fluid intake.

Institutionalized elderly were se- lected from three long-term-care fa- cilities. Noninstitutionalized sub- jects were solicited through personal contacts with friends and neighbors in the community.

The Short Portable Mental Status Questionnaire (slightly revised) was used to assess cognitive status(10). Disability levelin 18 activities of dai- ly living was rated by using the Rapid Disability Rating Scale-2(11). Addi- tional information about age, weight, height, activity level, education, and diabetes were gathered.

All subjects, after their selection, were instructed on the method for measuring and recording fluid intake for a period of three consecutive days. Fluid intake records were col- lected by the researcher and quanti- tative data analyzed.

It was interesting to note the re- sponse of the subjects to the study. Institutionalized clients were gener- ally eager to participate and wel- comed the chance to contribute in some way to knowledge about life in an institution. Rather than resent the mental status questionnaire that was part of the screening process, they seemed eager to demonstrate their cognitive skill. To have clear think- ing skills in an institution was a sta- tus symbol.

In contrast, the noninstitutional- ized subjects were somewhat offend- ed by the exercise of having to demonstrate cognitive ability by means of the mental status question- naire. No one actually refused to par- ticipate because of it, but another less formal measure of mental status evaluation would be recommended in similar follow-up studies.

Geriatric Nursing July/August 1988 219

The time pattern was similar in the two groups: There was almost no in- take at night, a sharp increase in the morning and afternoon, and a falling off again after 6:00 PM. In fact, over 75 percent of the fluid intake oc-

curred either at mealtime or at medi- cine time, indicating that the institu- tionalized elderly depended on nurses to offer fluids rather than ob- taining drinks for themselves.

Another observation was that pa-

Most of the fluid intake occurred at mealtime or medication time, implying that residents depended on nurses to offer fluids.

curred between 6:00 AM and 6:00 PM, with the highest intake in the after- noon.

However, the amount of fluid in- take was significantly higher for the noninstitutionalized elderly. While the mean daily fluid intake for the in- stitutionalized elderly was 1,507 ml, that of the noninstitutionalized el- derly was 2,115 ml. Institutionalized elderly essentially met the 1,500 ml norm for adults; noninstitutional- ized elderly exceeded the anticipated amount.

There were statistically significant differences between the groups in the type of fluid intake and the amount of fluid intake (p < .005). Institu- tionalized elderly drank about equal amounts of water and milk.

Water comprised only 31 percent of the daily intake of institutional- ized elderly, compared with 41 per- cent for noninstitutionalized elderly. The institutionalized elderly seemed to have less access to very cold and very hot drinks between meals, which may have affected their choice of beverage.

Nursing Implications Although findings were analyzed

for the two groups, the implications for nurses are considered primarily in relation to the institutionalized elderly.

The finding that the time pattern was similar for both study groups would imply that the institutional setting follows the usual life-style patterns. However, a closer look shows that most of the intake oc-

tients drank the amount offered. Ifa 90 ml container was offered, the pa- tient drank 90 ml; if 120 ml was of- fered, the patient drank 120 ml. To increase fluid intake for the institu- tionalized elderly, nurses might try offering a larger container of fluid at the time of medication administra- tion and mealtimes.

There were no complaints of thirst even though some subjects recorded up to 15 hours without fluids, indi- cating that nurses should not wait for complaints of thirst before offering fluids. Also, nurses should offer pa- tients drinks before instituting fluid restrictions at midnight for diagnos- tic procedures. This may prove to be particularly helpful because many in- stitutionalized elderly have already

had a 6-hour period without fluid in- take, in view of the pattern of re- duced intake after 6:00 PM.

The finding that the mean daily fluid intake of the institutionalized elderly was approximately 1,500 ml per day was reassuring. However, closer scrutiny indicated that even among these subjects who were rela- tively independent, 20 percent drank less than 1,000 ml per day.

Since the independent residents tended to drink only at meals and medication times, dependent institu- tionalized elderly may do the same. One wonders whether the dependent elderly who make up a large percent- age of the institutionalized elderly population would average less than 1,000 ml per day. Further research to compare the dependent and inde- pendent institutionalized elderly is recommended.

The description of the different types of beverages used by the two groups may have implications for nurses. One of the main differences was in water intake. The institution- alized elderly drank only about half as much water as the noninstitution- alized group even though water was available at all times. Reasons for this difference may relate to some studies cited earlier but were not ap- parent in this study. Further research is recommended.

The higher milk content for the in- stitutionalized elderly in place ofcof-

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220 Geriatric Nursing July/August 1988

fee or tea seems more nutritious. However, nurses should be aware that offering soft drinks, coffee, and tea, which were used more by the noninstitutionalized elderly, might help increase fluid intake. Of course, individual preferences always need to be considered.

In summary, there were significant differences in the fluid intake prac- tices of the institutionalized and non- institutionalized elderly. Further re- search on the reasons for this and on which nursing interventions are ef- fective in increasing fluid intake is recommended.

References

1. McConnell, John. Preventing urinary tract infec- tions. Geriatr.Nurs. 5:361-363, Nov.-Dec. 1984.

2. Branch, L. G., and Jette, A. M. A prospective study of long-term care institutionalization among lhe aged. Am.J.Public Health 72:1373- 1379, Dec. 1982.

3. Mahowald, J. H.,and Himmelstein, D. U. Hyper- natremia in the elderly: relation to infection and mortality. J.Am.Geriatr.Soc. 29:177-180, Apr. 1981.

4. Himmelstein, D., and others. Hypernatremie de- hydration in nursing home patients: an indicator of neglect. J.Am.Geriatr.Soc. 31:466--471, Aug. 1983.

5. Shock, N., and others. Patterns of longitudinal changes in renal function, lr~ Recent Advances in Gerontolog):" Proceedings of the 11th Congress of Gerontology held in Tokyo. Aug. 20-25.1978. (In-

tern. Congress Ser. No. 469) Princeton, N.J., Ex- cerpta Medica, 1979, pp. 525-527.

6. Epstein, M. Agingand the kidney:, clinical impli- cations. Am.Faro.Physician 31:123-137, Apr. 1985.

7. Phillips, P. A., and others. Reduced thirst after water deprivation in healthy elderly men. N.Engl.J.Med. 311:753-759, Sept. 20, i 984.

8. Hart, Monica, and Adamek, Constance. Do in- creased fluids decrease urinary stone function.'? Geriatr.Nurs. 5:245-248, July-Aug. 1984.

9. National Academy of Seiences, Food and Nutri- tion Board. Recommended Dietary Allowances. 9th ed. rev. Washington, D.C., The Academy, 1980.

10. Pfeiffer, E. A short portable mental status ques- tionnaire for the assessment of organic brain def- icits in elderly patients. J.Am.Geriatr.So¢. 23:433--441, Oct. 1975.

II. Linn, M. W., and Linn, B. S. The Rapid Disability Rating Seale-2. J.Am.Geriatr.Soc. 30:.378-382, June 1982.

What Determines How Much Patients Drink? A cluster of seven factors determine the type and amount of fluid residents receive.

PHYLLIS MEYER GASPAR

Inadequate fluid intake among the aged has been associated with such serious health problems as confu- sion, incontinence, and constipation,

Phyll is Meyer Gaspar , RN, PhD, is an assist- an t professor at the Gerontology Center, Uni- versity o f Utah, Salt Lake City, UT.

The au thor wishes to acknowledge the nurs- ing h o m e residents, nurse observers, disserta- t ion commit tee , and Dr. Mary Adams, chair, for their assistance in this study.

all of which fall within the scope of nursing practice(l-4). Yet, a search of the literature revealed only two nursing studies documenting the fluid intake of elderly persons.

In 1962, 18 patients on a geriatric unit in an English hospital were ob- served foi" a 24-hour period(5). Among the observations, the re- searchers found that only one patient had an adequate fluid intake of more than the minimum requirement of 1,500 ml per day.

Twenty-two years later, a study was conducted of nursing home resi- dents to determine whether a fluid intake of 2,000 to 3,000 ml per day would prevent urinary catheter blockage(6). The results of this study

suggested that even when nurses en- couraged an increase in fluid intake, subjects did not achieve the goal.

Do Certain Variables Pinpoint Adequacy?

What is the association of the ade- quacy of water intake with subjects' characteristics, situational condi- tions of ingestions, and presence of conditions that require an increased need for water intake? Which of these variables discriminate between nurs- ing home residents with adequate water intake and those who do not?

For purposes of this study, water intake was determined from food and fluids ingested. When reference is made to fluid intake, liquids gener-

Geriatric Nursing July/August 1988 221