Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision.

OBJECTIVE: To investigate the factors that influenced fluid intake among nursing home residents who were not eating well. DESIGN: A prospective, descriptive, anthropological study. SETTING: Two proprietary nursing homes with 105 and 138 beds, respectively. PARTICIPANTS: Forty nursing home residents. MEASUREMENTS: Participant observation, event analysis, bedside dysphagia screening, mental and functional status evaluation, assessment of level of family/advocate involvement, and chart review were used to collect data. Data were gathered on the amount of liquid served and consumed over a 3- day period. Daily fluid intake was compared with three established standards: Standard 1 (30 mL/kg body weight), Standard 2 (1 mL/kcal/energy consumed), and Standard 3 (100 mL/kg for the first 10 kg, 50 mL/kg for the next 10 kg, 15 mL/kg for the remaining kg). RESULTS: The residents' mean fluid intake was inadequate; 39 of the 40 residents consumed less than 1500 mL/day. Using three established standards, we found that the fluid intake was inadequate for nearly all of the residents. The amount of fluid consumed with and between meals was low. Some residents took no fluids for extended periods of time, which resulted in their fluid intake being erratic and inadequate even when it was resumed. Clinical (undiagnosed dysphagia, cognitive and functional impairment, lack of pain management), sociocultural (lack of social support, inability to speak English, and lack of attention to individual beverage preferences), and institutional factors (an inadequate number of knowledgeable staff and lack of supervision of certified nursing assistants by professional staff) contributed to low fluid intake. During the data collection, 25 of the 40 residents had illnesses/conditions that may have been related to dehydration. CONCLUSIONS: When staffing is inadequate and supervision is poor, residents with moderate to severe dysphagia, severe cognitive and functional impairment, aphasia or inability to speak English, and a lack of family or friends to assist them at mealtime are at great risk for dehydration. Adequate fluid intake can be achieved by simple interventions such as offering residents preferred liquids systematically and by having an adequate number of supervised staff help them to drink while properly positioned.

The effect of role-taking ability on caregiver-resident mealtime interaction.

In this qualitative study of mealtime in a nursing home, data were collected on the verbal and nonverbal interaction between certified nursing assistants (CNAs) and completely eating-dependent residents. Although some caregivers were seen to give care in a creative, empathetic manner, others were task-driven and mechanistic. The difference in caregiving was, in part, accounted for by the degree to which individual caregivers were able to engage in role taking, that is, the ability to see the world from the resident's perspective. Recommendations for enhancing role-taking ability include (a) asking caregivers to reflect on their own mealtime experiences, (b) encouraging staff to eat with residents, (c) having staff practice feeding one another, and (d) providing role modeling and supervision by professional nursing staff at mealtime.

A prospective study of the use of liquid oral dietary supplements in nursing homes.

OBJECTIVE: To investigate the use of liquid oral dietary supplements among nursing home residents who were eating poorly and losing weight. DESIGN: A prospective, descriptive, anthropological study. SETTING: Two proprietary nursing homes with 105 and 138 beds. PARTICIPANTS: Purposive sampling was used to select 40 residents from among the 100 residents who were not eating well. Dietary data were collected on this sub-sample of 40 residents. MEASUREMENTS: Participant observation, in-depth interviews, event analysis, bedside dysphagia screenings, oral health examinations, body weight, body mass index (BMI), and chart review were used to collect data. Dietary data were collected over a 3-day period, and data were gathered on how supplements were ordered, served, and consumed. RESULTS: Supplements had been ordered for 29 of the subsample of 40 residents. Only nine of 29 residents were served the correct number and type of supplements as ordered by their physicians, and only two residents consumed the full amount of supplement as ordered. The overall mean percentage of supplement consumed compared with that ordered was 55.1%. Although supplements were ordered primarily to prevent weight loss and to facilitate weight gain, nearly half (n = 14) of the residents continued to lose weight. Supplements were ordered without investigating the underlying factors contributing to weight loss, such as inadequate staffing and lack of supervision at mealtime, undiagnosed dysphagia, and poor oral health. Without evaluation of these factors, it is unknown which residents might benefit from oral supplements. CONCLUSION: Findings indicate that supplements were used nonspecifically as an intervention for weight loss in nursing home residents without regard to dose, diagnosis and management of underlying problem(s), amount of supplement consumed, and outcome. Further research is needed to establish when supplements should be ordered, how to ensure that they will be taken, and whether they are effective.

Strategies for conducting dental examinations among cognitively impaired nursing home residents.

Many nursing home residents have poor oral health and are in need of treatment. A major barrier to providing care is the difficulty of examining cognitively impaired elders. In two research studies, 625 exams were conducted on 181 nursing home residents, the majority of whom suffered severe cognitive impairment. Qualitative data collected during the course of these two studies revealed strategies that permitted examiners to conduct the examinations successfully, including developing rapport with the residents, providing a quiet environment, and enlisting the help of the primary caregiver. The importance of interdisciplinary collaboration among health professionals, especially dentists and nurses, is discussed.

An instrument to assess the oral health status of nursing home residents.

This article presents data from the development and testing of an instrument to evaluate the oral health of nursing home residents by nursing personnel (RNs, LVNs, and CNAs). After the instrument was developed, nursing staff were taught to do a brief oral health status examination (BOHSE). Using the instrument, a dentist examined 100 residents; the examination was repeated on the same residents by each category of nurse examiners. Correlation coefficients indicate that statistically significant interrater reliability between the three categories of nursing personnel and the dentist was established, suggesting that nursing staff can be taught to evaluate the oral health of residents. Replication of the study in multiple sites is recommended.