Get Wet for Wellbeing

Get Wet for Wellbeing – Leah Bisiani –

“Keeping Hydrated keeps you Upright”

Older vulnerable Australians, especially the 65+ age group, residing within Residential Aged Care Facilities, (RACFs), have been identified as a cohort that are deemed to be at substantial risk of falling and sustaining serious fall related injury, as a result of those falls.

Given there is significant evidence stating falls are one of the leading causes of hospitalisations in older Australians, it is crucial that our attention focuses on, and a dialogue is initiated, in relation to falls prevention strategies that are urgently required to address this disturbing fact.

The causative factors and the reasons for older people falling are diverse and varied, however, it is suggested that when discussing falls, it is helpful to classify them into categories’, to identify and lessen the probability of falls and serious fall related injury, so we may promote implementation of preventative actions that endorse a robust risk minimisation approach to care.

It seems reasonable to link falls and impaired mobility in our older population to many factors, however, this study focuses specifically on one area of concern, and examines the direct impact associated with dehydration, and how maximising adequate fluid levels may effectively reduce and prevent frequent falls in older Australians living in RACFs.

Types of falls

The most common causative factor in relation to falls are what are classified as anticipated falls.
These are directly associated with intrinsic factors, such as health status, medical conditions, cognitive changes, and physical ability.
Falls that occur because of intrinsic factors are the most receptive to assessment and intervention, and the results are usually favourable.
The “Get Wet for Wellbeing” program fits into this category.

The second most common cause of falls are accidental falls, which in general, are related to environmental hazards, or extrinsic influences.
For instance, obstacles in walkways, mats and rugs that slide on the floor, glare, clutter, moving furniture in the room of someone who is visually impaired, uneven pathways, or unsafe, poor fitting footwear.

Lastly, we have non anticipated falls, which are unable to be predicted, and can occur at any time, for any reason, to anyone, regardless of age, health status, cognitive ability, or physical capability.

Oral Hydration – The Need

Water is the most needed nutrient required to sustain life, other than oxygen.
People can live without food for a month or more but can only survive 3-4 days without water.

Water makes up 85% of the blood, 70% of muscles and approximately 75% of the brain, and is present within and without every single cell in our bodies.

In the body, water has many purposes.
It acts as a solvent, coolant, lubricant, and transport agent.

Water regulates body temperature, removes toxic waste, carries nutrients, and provides a medium in which cellular chemical reactions can take place.

Dehydration occurs when we consume less water than what we lose, through the skin, lungs and/or body waste.

Firstly, it is crucial we consider how our older population residing in RACFs are definitely and unquestionably considered to be at heightened risk of dehydration, because their bodies contain a lower water content that younger persons.
An older person weighing about 65-70kg will have about 7 litres less water in their body, than someone of the same weight who is 20 years younger.

Consequently, our older residents may become dehydrated much quicker than someone who is younger.

Adequate levels of oral hydration are a constant need requiring vigilance at all times, especially in hot climates, and during summer months, and is essential for maintaining optimum health and physical wellbeing.

It is already clear that our older population suffer most from poor oral fluid intake, and this potentially affects and impacts on their lifestyle, and is one factor that seems to be directly related to impaired mobility, and increased falls risk as a result of dehydration. This, in turn, may be the catalyst to ongoing development of urinary tract infections, (UTIs), declined cognition, diminished muscle tone, lessened functional ability, and/or orthostatic hypotension causing dizziness when upright.

Due to visual impairment, physical changes, and living with multiple co-morbidities, (many associated with pain and discomfort), older persons may moreover have difficulty obtaining fluids for themselves regularly.
They may have a muted sense of thirst, poor insight into the need to remain hydrated, have poor access to fluids, may consciously restrict intake for fear of incontinence, and at times, there may be a lack of compliance by staff within RACFs regarding maintenance of adequate hydration.

These considerations may additionally be further compounded if the person lives with dementia.
As a result of changed cognition and increased vulnerability, people living with dementia may be placed at a significantly higher risk, due to changes in comprehension, insight, judgement, and problem-solving ability.
It could be surmised that people living with dementia are placed at the most extreme end of the scale of risk.

Therefore, it is evident that as caregivers, we must perpetuate an awareness on how the basic elements related to improved hydration may positively impact on the reduction of falls in our older population, particularly those living with dementia.

When delivering care, it is the responsibility of the caregiver to ensure residents under their care are thoroughly assessed in regard to their specific needs in relation to oral hydration, ensuring a thorough understanding concerning the basic strategies required to reduce risks associated with anticipated falls.

It could be considered that these essential and primary care needs should be deemed a compulsory part of the ongoing and fundamental frameworks of quality care delivered to each person.

The ‘Get Wet for Wellbeing’ Project was developed after identifying how this significant area is often unintentionally overlooked when assessing each resident, and how oral hydration seemed pointedly linked to consistent falls.

When examining the risks associated with oral hydration and connecting this information to impaired mobility, it was possible to utilise this material in the planning of conducive preventative strategies when care planning for each resident.

These simple care modifications resulted in numerous and astounding benefits.

Dehydration
Dehydration in effect, is the starting point for a multitude of complications and conditions that directly influence a residents’ ability to function at an optimum level in every aspect of their lifestyle, inclusive of mobility and transfer.

The older cohort we care for are more susceptible to dehydration due to age related changes.

It has also been observed that confused older people are more likely to have a lower fluid intake over a 24-hour period than lucid older adults.

Obviously, gastrointestinal conditions may affect hydration if the person is losing significantly higher amounts of fluid through vomiting and diarrhoea.
The adverse consequences will become increasingly serious if input becomes substantially less than output for an extended period of time.

It is also worth considering how the use of diuretics may create a situation where a person becomes severely dehydrated, if dosages are not monitored, and if we are not aware of the risks associated with these medications in context.

Dehydration may arise when an older person’ dietary input is low or minimal, given much of the food we consume contains water.

During the study it became evident that some residents who experienced frequency, or urge/stress incontinence, were intentionally and purposefully reducing their fluid intake, and making a conscious, (and concerning), decision, to limit fluids to diminish incontinent episodes and/or the need for toileting.

It became essential to inform staff and residents about how the restricting of fluids in this manner may eventually lead to dehydration, irritation of the bladder as a result of more concentrated urine, increase the incidence of frequency, urgency, and the need to void (but in small amounts), and quite rapidly lead to urinary tract infections (UTIs), trigger acute delirium, and potentially escalate risk.

As already briefly discussed, hot weather, especially during mid-summer may be relatively dangerous for the older resident, if the necessary precautions are not considered.

Therefore, causes and complications associated with dehydration include, and are not limited to, inadequate fluid intake(orally), fluid loss, (i.e., vomiting, diarrhoea, increased voiding), and environmental factors, (i.e., hot temperatures, air conditioning).

It is vital that staff immediately recognise the signs of dehydration and act promptly to resolve dehydration occurring, so they may effectively prevent further clinical deterioration and ongoing complications.

Indicators of dehydration may include:

• Lethargy • Fatigue
• Headache

• Increased pulse – tachycardia
• Decreased blood pressure/postural hypotension
• Dizziness
• Irritability
• Muscle cramping
• Constipation
• Scanty output (urine) with possible urgency
• Concentrated urine/increased strong odour
• Poor skin integrity – lack of skin elasticity/poor skin turgor
• Limb muscle weakness
• Tongue furrows
• Sunken eyes
• Dry mucous membranes
• Decreased healing ability because of reduced health status
• Changed behaviour
• Confusion
• Sudden incontinence
• Nausea
• Febrile episodes
• Speech difficulties
• Weight loss
• Shock Common signs of a UTI: (some of the symptoms overlap with dehydration indicators but may worsen over time)
  • Dysuria – pain/burning sensation when passing urine
  • Frequency and urgency/if only to pass a few drops
  • Frequency at night (nocturia)
  • Cloudy concentrated urine
  • Haematuria – blood in urine
  • Sediment in the urine
  • Strong/foul smelling urine
  • Pain above the pubic bone
  • Fever
  • Change in behaviour
  • Acute delirium/confusion
  • Anorexia
  • Falls NB: Complications associated with the signs and symptoms of UTIs increase the probability of falling for the following additional reasons:

1. confusion increasing risk taking behaviour
2. sustaining of serious injury by attempting to toilet self unaided, and without the required/necessary assistance
3. trying to get quickly to a toilet and rushing due to urgency, thus falling
4. attempting to deal with clothing adjustment and hygiene too quickly and losing balance, or tripping on clothing
5. being unable to hold on long enough to sit on the toilet, and voiding on the floor creating a slip hazard

Infection and Delirium
Dehydration may, as discussed, increase the incidence of UTIs and the likelihood of other infections, which in turn

creates further, and extreme complications; the most major being the acute onset of acute delirium.
Acute delirium is a serious and life-threatening condition, and is considered a medical emergency, especially if left

untreated.

Older people living with dementia are considered to be at especially high risk of acute delirium, due to the additional vulnerabilities associated with their cognitive changes.

When a resident is severely dehydrated and has developed an infection that has led to an acutely delirious state, it is highly likely that the grave nature of this ensuing clinical deterioration, may create a substantial decline in cognition and functional ability, which in turn exacerbates any mobility/transfer difficulties, placing the resident at an extreme risk of falling.

Furthermore, regardless of cognition, the critical nature of acute delirium, may alone cause immediate and rapid decline in overall physical ability of any older person. Acute delirium is an unfavourable medical condition, is detrimental to a resident mobilising safely, and may eventually lead to an excessive decline in co-ordination, sufficiently debilitating enough to precipitously increase the risk of falling and serious fall related injury.

NB: it is important never to assume acute changes related to the clinical, cognitive, and physical presentation of a person living with dementia are due to an exacerbation of dementia.

Subsequently, by maximising oral input, and through early detection and treatment of acute conditions through recognition of clinical deterioration, occurring as a result of dehydration, we may effectively prevent the prevalence of accidental falls, and consequentially avoid serious fall related injury.

Aims

• To effectively manage the oral intake and hydration of all residents within the aged care residential setting.
• Ensure resident input is maximised, reducing the incidence of falls and serious fall related injury, that are directly related to dehydration.
• To prevent the occurrence of infection and related complications, such as acute delirium, of which may directly affect mobility and transfer.
• To improve quality of life and wellbeing by reducing the risks associated with falls and serious fall related injury.
• To improve resident health, muscle tone, skin integrity, balance, independence, and welfare by implementing adequate oral input.
• Demonstrate through the imparting of knowledge, an increased awareness by all care staff regarding the relevance and importance of oral hydration in maintaining quality of life and improved functional/cognitive ability in residents. Methodology approach and Interventions To provide maximum effect and to illustrate the benefits of oral hydration, the key season targeted was spring and summer, in which increased environmental temperature often and traditionally led to an increase in UTIs, and dehydration in our older residents, specifically those living with dementia.

However, the complete study was conducted from September 2002 until August 2003, so as to establish a more robust collection of supportive data.

All 45 residents residing in the RACF were included in the pilot group, given the importance and significance of hydration to all residents residing within the facility.

All 45 residents had a diagnosis of dementia, with 35 out of the 45 having reached moderate to advanced cognitive changes.

Qualitative and quantitative data was collected, collated, and evaluated monthly, examining the incidence of falls and fall related injury.
The prevalence of infections was captured in the same manner.

It was necessary to compare the figures of the previous year against the figures of the current year, and gain insight into whether improved oral hydration made a significant difference, through data comparisons.

Education of all care and catering staff prior to the study was essential, incorporating every aspect related to the optimisation of oral hydration, and the rationale behind the implementation of the “Get Wet for Wellbeing” Project, in context, so as to elucidate the ongoing benefits in relation to falls prevention.

Care and catering staff were requested to attend a compulsory session on the project, active discussion occurred, and all staff were given the opportunity to provide valuable input into strategies, so that the project could be straightforward and easy to maintain throughout each shift.

Family members and residents were given the opportunity to attend education and information sessions related to the relevance of hydration to quality of life, wellbeing, and mobility, and memos were circulated explaining the “Get Wet for Wellbeing” program.

Thus, the planning of the study, and the implementation of hydration interventions were initiated through a robust and collaborative approach.

It was possible to immediately introduce the active hydration strategies, once all staff were informed, aware and committed to maintaining the new and optimum hydration programs.

The following strategies and interventions were implemented in September 2022:

• Ascertained all residents’ specific likes and dislikes, preferences, and choices regarding hydration, possible allergies, and all relevant individualised information.
• Resident capabilities and individualised information were captured and reflected clearly in all documentation, assessments, care plans, and catering forms.
  As resident needs changed the information was clearly captured and updated immediately and communicated to all relevant care and kitchen staff.
• A list of at-risk residents was developed, and a copy placed in the care office and kitchen – this information outlined the rationale for any resident being identified at high risk of dehydration – e.g., frequent falls, frailty, pain, cognition, decline in input etc.
• Residents on fluid restrictions were flagged by a colour coding system on their files, on all kitchen lists, and on the ‘hydration trolley’ lists, to ensure those residents did not exceed their daily limit.

• Care staff ensured accurate completion of fluid balance charts for all residents who required them, on a daily basis.
• Residents in the early stages of cognitive impairment were educated on maintaining adequate fluid levels.
• Ongoing observation of resident consumption of fluids was conducted and any concerns were reported and recorded in nursing notes for follow up.
• Dehydration signs and symptoms charts were displayed in the care office to support ongoing staff awareness.
  This prompted staff to conduct routine monitoring of all residents every time they had contact with them and report any signs of dehydration immediately.
• Established hydration program for all residents were communicated with care and kitchen staff, incorporating responsibilities, frequency of hydration rounds, (hourly), what to offer, how to encourage and assist hydration, and how to include these rounds as part of the care.
  NB: older people tolerate more frequent fluids in small quantities rather than infrequent quantities in large amounts.
• Water fountains were placed in all common areas of the facility. Kitchen staff always ensured an adequate stock of disposable cups.
• A fresh bottle of water was placed in every resident’s room every day, on their bedside table, with the cap loosened to ensure ease of opening.
  A cup was placed by the bottle and replaced with a clean cup every day.
• Bottles were to be replaced as soon as they were empty, regardless of how many bottles were required a day.
• Fresh bottles of water, jugs of iced water and cordial were always filled and available on every dining room table throughout the day.
• Bowls of finger sized/peeled and chopped high water content fruits were placed in common areas, on tables, within view, so that residents who strolled around frequently may be tempted to consume the fruit.
• Kitchen staff would set up a trolley every hour with a selection of hot and cold drinks, high water content fruits chopped into manageable bite size pieces in cups, icy poles, ice cream, jelly cups etc. for care staff to take around the facility, ensuring every resident was given something.
• Cold drinks included an adequate selection of alternatives and a suitable variety of water, soda water, soft drinks, cordial, blended smoothies, milk shakes, slushies, punches, fruit juices, based on resident preference.
• High water content fruits included watermelon, cantaloupe, berries, oranges, mandarins, peaches, pineapple, grapes – all peeled, cut up into manageable finger sized pieces and placed in small cups for ease of access.
• Icy poles, ice creams, jelly cups, frozen pureed fruit in icy pole moulds were great examples of delicious icy treats.
• Warm drinks include coffee, tea, hot chocolate, soups, and clear broths.
• Morning tea, afternoon tea, and supper rounds would include the offer of tea and coffee as per resident preference, however, other fluids were included and encouraged during these rounds.
  If possible, minimising of caffeine occurred due to the diuretic impact of these beverages, but only if the resident was amiable to it.
• Provision of alternatives to coffee drinkers – such as non-caffeinated coffee.
• Staff were encouraged to always know and provide preferred drinks for residents to encourage their compliance.
• A supply of straws and special mugs/sipper cups were always on the trolley to ensure correct equipment was provided for residents to aid and ease drinking.
• All drinks were placed within easy reaching distance for residents on stable surfaces.
• Hot drinks were not to be left to go cold if a resident was not present in their room.

Staff were to locate the resident and provide them with their drink (if able).

• Staff to utilise positive statements and approaches when delivering hydration. Instead of asking “are you thirsty would you like a drink?”, make positive comments like,” here is a lovely refreshing drink for you”, or “here is your favourite fruit juice”…..
• Staff reminded, encouraged, and prompted residents to have a drink every time they interacted with them – i.e. After a shower, after toileting, during activities.
• Residents with moderate to advanced cognitive changes were adequately assisted in regard to cues, verbal prompting, reminding them to drink, making sure drinks were within range and within eyesight.
• If a resident required hands on physical assistance, then this was provided – e.g., when providing the residents favourite beverage, use of the correct aids such as straws and special cups, placing a drink in the residents’ hand and guiding it to their mouth with verbal encouragement, and/or prompting them to swallow.
• All icy poles and ice creams were unwrapped, and handed to the resident, whilst making a positive statement about how delicious the icy pole must be.
  Icy poles, ice creams, and fruity treats were especially important in the summer months, and delicious. None of these products were to be left on a table, still in the packaging, to melt.
• When drinks were provided with medication administration, resident glasses were filled instead of providing just a mouthful of fluid to swallow tablets.
• Light broths and soups were always offered during meals.
• Residents were encouraged to have meals and snacks together, given many residents tended to consume more fluids in a social setting.
  Staff assisted and poured drinks throughout the meals, if and as required, placed cups within reaching distance and in the correct receptacle for the resident.
• Dietary intake was monitored, and maximised and food charting initiated if there were concerns.
• Use of colourful props to jazz up glasses, swizzle sticks, slices of lemon, and groovy straws presented a more attractive and appealing prompt to having a drink.
• Use of brightly coloured glasses, or wine glasses that were similar to those previously used by residents were familiar and more likely to be used by a resident.
• Residents who enjoyed an alcoholic beverage daily were provided the beverage of preference.
• A variety of beverages, drinks and high water content snacks were offered throughout all lifestyle activities.
• Some lifestyle activities became focused on and involved making drinks such as homemade lemonade, fruit punches and other delicious drinks, that could be enjoyed as they were made.
• Taste test lifestyle activities required tasting of up to 10 different fluids and playing guessing games and became a fun way to consume more fluids.
• Plentiful cold drinks, iced water and beverages were always provided for all outings.
• Happy hour was introduced twice to three times a week, with alcohol for residents who would like a drink, non-alcoholic wines, mocktails, soft drinks, and nibbles.
• When family, friends and relatives visited, a drink was offered so that the social aspect of having a drink would be shared.
• Staff would maintain and provide frequent drinks if residents were outside.
• Time spent outside in the hottest part of the day was reduced in summer months and hot days.
• Residents were encouraged to be sun smart, and wear hats outside when it was warm, apply sunscreen, and wear light and cotton clothing.
• Residents were dressed in appropriate clothing related to the weather.
• Outdoor activities were scheduled before 10am and after 2.30pm when the days were hot.
• Bus outings were cancelled if the temperature was over 32 degrees.
• Vending machines were installed with a selection of cold drinks.
• Coffee, tea and hot chocolate machines were placed in communal areas.

It was noted and documented that the following comments were made by staff and/or residents at the commencement of the program:

1. Some residents and staff still expressed concern regarding the potential worry associated with increased voiding and toileting, the additional time spent mobilising to and completing toilet needs, and the possible increased care burden to staff, as a result of increased hydration.
2. Staff expressed concern regarding the additional time the hourly hydration rounds took, and the impact this seemed to be having in relation to completion of resident care in a timely manner.

The following responses were provided, and it was confirmed that they were satisfactory:

1. It was reinforced that dehydration is more likely to cause a higher degree of urgency, and result in more frequent visits to the toilet, whereas increasing hydration, was unlikely to cause the level of frequency that was of concern.
2. This response also applied to the concerns regarding care burden.
3. A staff meeting was held where it was again reinforced that the hourly hydration rounds, would initially take some additional time, however:
   1. The Manager and senior staff would assist with the delivery of hydration rounds so that care needs would not be compromised.
   2. It was emphasized that the substantial benefits of the hydration program would balance out quite quickly and care would not be impacted upon, and once this was the case, the time would not interfere with care in any way.
   3. Further discussions occurred supporting the rationale that when residents were well hydrated, caregivers would notice a reduction in the time associated with the quite considerable care burden related to frequent infections, falls, serious fall related injury, acute delirium, and changed behaviour. This in turn would increase the amount of productive hands-on time, allowing caregivers to deliver optimum care.

Further interventions were established to ensure resident toileting needs were met and conducted safely at all times:

• Adequate and thorough assessment and management of bladder/bowel control was completed, to ensure residents individual toileting and continence needs were captured and reflected in care plans.
  This included assistance required with all aspects of continence, toileting schedules, and preventative management measures initiated to ensure prevention of falls risk and serious fall related injury.
• Toileting regimes/schedules were initiated for all residents who were considered a high falls risk and for residents living with moderate to advanced dementia, with a focus on the amount of supervision, prompting and hands on assistance required.
• Residents with urinary and faecal incontinence were assisted to maintain social continence through toileting schedules.
• Incontinent resident wore incontinent aids, in which staff assisted with changing and disposal of, as required. Adequate supply and bags for disposal of soiled aids were always placed in the bathrooms.
• Independent residents were encouraged to leave their bathroom lights on and the bathroom door open for easier access. At night a night light was provided.
• Staff ensured a plentiful supply of toilet paper, aids, hand towels and equipment and devices were always in place.
• Bathroom floors were wiped down after use by staff.
• Residents were prompted to use grabrails at all times when transferring on and off the toilet.

Results

Data was collected and evaluated throughout September 2002 until the end of August 2003, focusing on the maximisation of oral hydration for all residents, and examining whether the implementation of the “Get Wet for Wellbeing” program, directly and positively impacted on improved resident mobility, reducing falls and serious fall related injury.

Evidence was established through collating and summarising the number of monthly fall related incident reports, identifying monthly infection control statistics, and comparing the data to the previous year.

After examining these two areas, it was heartening to discover that not only had the occurrence of falls reduced dramatically, but the reduced incidence of chest infections and UTI’s also favourably coincided with these results.

The results were encouraging, and the following was established through the evaluation of the data (with additional unexpected results):

• Incident reports for anticipated falls, reduced significantly from 6-11 month to 1-3 month.
• Even though falls reduced there was still a minority of residents who had non-anticipated falls with 5 unanticipated falls within the year/12 months.
• It was interesting to acknowledge that with the 5 unanticipated falls, none sustained injury, skin tears or lacerations, thus no serious fall related injury.
• Infection control statistics showed a substantial decline in UTI’s, (especially over summer), from 8-12 a month, to 0-3 a month.
• There were nil UTI’s recorded during the colder months between March-August 2003.
• Chest infections reduced dramatically, showing a decrease from 7-11 a month, to 1-3 a month throughout winter.
• There were nil chest infections from January-April 2003.
• There was nil incidence of acute delirium as a result of dehydration.
• There was a significant reduction in dehydration related hospital admissions from 3-5 month to 0 from January-August 2003.
• Resident changed behaviour reduced significantly regarding anxious and agitated behaviour, with nil incident reports filed from January 2003 related to physical or verbally aggressive behaviour.
• Improved social interaction with other residents was noticed in all residents with moderate to advanced dementia. (35 residents)
• Improved activity and maintenance of independence was evident with all 45 residents.
• There was some improvement in cognitive scores based on the Mini-Mental Examination of between 1-4 points, for 30 of the residents with moderate to advanced dementia.
• There was a considerable reduction in time spent off the floor delivering care to residents’ post falls, managing residents who were unwell with infections and/or acute delirium, and managing resident changed behaviour, which then created a scenario whereby care staff had additional time available to deliver a higher quality level of care to all residents. Consequently, it was possible to establish and demonstrate that the provision of increased and adequate oral hydration to older residents living with dementia residing in RACF’s, successfully and positively reduced the incidence of dehydration in this cohort, thus significantly reduced the prevalence of falls and serious fall related injury. Further examination of the figures additionally leads to the obvious conclusion that infections resulting in acute delirium, were also closely linked to poor oral hydration and dehydration and may contribute to a decline in mobility/ transfer and physical/functional status.

It was evident that when residents were no longer unwell or acutely delirious, the incidence of falls again reduced considerably.

It was also encouraging to note the further and exciting benefits drawn from the data, including evidence to support an overall and noticeable improvement in resident skin integrity, increased socialisation, a reduction in changed behaviour, and the very promising indicators that when well hydrated, a person living with dementia exhibits improved cognitive ability.

With the overall improvement in resident presentation, and the resultant reduction in time spent caring for people when they were presenting as frailer, less mobile, exhibiting changed behaviour and/or were unwell, care staff became empowered.
They were, able to deliver quality care to residents, unhampered by the number of time related complications associated with dehydration.

The benefits of this study were enormously inspiring and exciting, and clearly established how the simple association between hydration and falls is paramount to quality outcomes and should be considered as a principal way forward in supporting and upholding better practice approaches to care.

Furthermore, it is crucial as caregivers that we recognise the critical nature of basic care needs such as hydration, and the direct impact it has on providing quality care that is responsive in nature to the older cohort of people we are committed to caring for, in a manner that optimises a robust lifestyle, acknowledges how strength and physical health aligns with well-being, and how we can enable those we care for to live their best life.

Let’s drink to that!!!!!!!!!!!