Managing Oral Hydration in Old Age
Dehydration in Old Age
A recent study using markers (serum sodium, osmolality, and blood
urea nitrogen [BUN]/creatinine ratio) for dehydration and volume depletion from
the Established Populations for Epidemiologic Studies of the Elderly (EPESE:
Stookey , Pieper, & Cohen, 2005 ).
National Health and Nutrition
Examination Survey III (NHANES III: Stookey , 2005) found that the prevalence
rate for these conditions in community-dwelling older adults could range from
0.5% to 60% depending on the markers used.
Another study found that 48% of
older adults presenting with dehydration at an emergency room (ER) unit were
from the community (Bennett, Thomas, & Riegel, 2004).
Maintaining adequate
fluid balance is an essential component of health across the lifespan: older
adults are more vulnerable to shifts in water balance both overhydration and
dehydration because of age related changes and increased likelihood that an
older individual has several medical conditions.
Dehydration is the more
frequent occurrence in older adults (Warren et al., 1994; Xiao, Barber, &
Campbell, 2004). In fact, avoidable hospitalizations for dehydration in older
adults have increased by 40%
Developing and Evaluating Clinical Practice Guidelines: A Systematic
Approach, page 7. Note. Portions of this chapter were adapted with permission
from Mentes, JC, & Kang, S. (2010).
Evidence-based protocol: Hydration
management. In MG Titler (Series Ed), Series on evidence-based practice for
older adults. Iowa City, IA: University of low a College of Nursing
Gerontological Nursing Interventions Research Center, Research Translation and
Dissemination Core.
From 1990 to 2000, at a cost of $1.14 billion (Xiao et al.,
2004), and is one of the Agency for Healthcare Research and Quality’s 13
ambulatory care-sensitive conditions.
Not only will careful attention to
hydration requirements of older adults help prevent hospitalizations for
dehydration but will also decrease associated conditions such as acute confusion
and delirium (Foreman, 1989; Mentes & Culp, 2003; Mentes.
Culp, Maas, &
Rantz , 1999 ; O’Keeffe &Lavan , 1996; Seymour, Henschke , Cape, &
Campbell, 1980); adverse drug reactions (Doucet et al., 2002); infections (
Beaujean et al., 1997: Masotti et al., 2000); and increased morbidity
associated with bladder cancer (Michaud et al., 1999).
Coronary heart disease
(Chan, Knutsen , Blix, Lee, & Fraser, 2002; Rasouli , Kiasari , & Arab,
2008), stroke (Rodriguez et al., 2009), and other thromboembolic events (Kelly
et al., 2004).
Further, dehydration has been associated with longer hospital
stays for rehabilitation ( Mukand , Cai, Zielinski, Danish, & Berman, 2003)
and for readmission to the hospital (Gordon, An, Hayward, & Williams,
1998). Even in healthy community-dwelling older adults, physical performance
and cognitive processing is affected by mild dehydration (Ainslie et al.,
2002).
Oral hydration of older adults is particularly complex for a
variety of reasons. In the following review, issues of age-related changes,
risk factors, assessment measures, and nursing strategies for effective
interventions for dehydration are addressed.
Background and statement of problem
Water is an essential component of body composition. Intricate
cellular functions such as gene expression, protein synthesis, and uptake and
metabolism of nutrients are affected by hydration status.
Organ systems,
specifically the cardiovascular and renal systems, are particularly vulnerable
to fluctuating levels of hydration (Metheny, 2000).
Older individuals are at increased risk for hydration problems
stemming from several converging age-related factors including lack of thirst
(Ainslie et al., 2002: Phillips.
Bretherton, Johnston, & Gray, 1991;
Phillips et al., 1984); changes in body composition, specifically loss of fluid
rich muscle tissue ( Bossingham , Carnell, & Campbell, 2005).
Increasing
inability to respond efficiently to physiological stressful events where
dehydration results (Farrell et al., 2008; Rolls, 1998); and renal changes including
a reduced renal capacity to handle water and sodium efficiently (Macias- Nuñez
, 2008).
Additionally, personal, often lifetime by duration habits, may
contribute to risk but have not been explored in relation to underhydration. As
a result, older adults are often at risk for a chronic state of underhydration.
Several studies ( Bossingham et al., 2005; Morgan, Masterson, Fahlman, Topp .
&Boardley , 2003; Raman et al., 2004) of community dwelling older adults
suggest that under normal conditions, older adults maintain adequate hydration;
however, when challenged by environmental stressors-physical or emotional
illness, surgery, or trauma-they are at increased risk for dehydration and
rapidly become dehydrated if they are already chronically underhydrated.
What is dehydration
Dehydration is the depletion in total body water (TBW) content
caused by pathologic fluid losses, decreased water intake, or a combination of
both. It results in hyper-natremia (more than 145 mEq/L) in the extracellular
fluid compartment, which draws water from the intracellular fluids.
The water
loss is shared by all body fluid compartments and relatively little reduction
in extracellular fluids occurs. Thus, circulation is not compromised unless the
loss is very large.
Under Hydration
Under-hydration is a precursor condition to dehydration associated
with insidious onset and poor outcomes (Mentes, 2006; Mentes & Culp, 2003).
Others have referred to this condition as mild dehydration ( Stookey et al.,
2005) or chronic dehydration (Bennett et al., 2004).
Assessment Of The Problem
Assessment of hydration status consists of risk identification with
attention to specific populations at increased risk, assessment of hydration
habits, and evaluation of specific biochemical and clinical indicators.
Risk Identification
Risk for dehydration in ill or frail older adults across care
settings has been more frequently studied.
Although there is no outstanding
risk factor for dehydration, age, gender, ethnicity, class, and number of
medications taken, level of activity of daily living (ADL)
Dependency, presence
of cognitive impairment, presence of medical conditions such as infectious
processes, and a prior history of dehydration have all been associated with
dehydration in older adults (Mentes &lowa -Veterans Affairs Nursing
Research Consortium [IVANRC], 2000).
Therefore, although single risk factors
will be discussed, it is likely that clusters of risk factors maybe more
helpful in clinical settings (Leibovitz et al., 2007).
Increasing age is associated with increased likelihood of
dehydration (Ciccone. Allegra, Cochrane, Cody, & Roche, 1998;
Lavizzo-Mourey , Johnson, &Stolley , 1988; Warren et al., 1994).
Ciccone
and colleagues (1998) found that adults aged 85 years and older were three
times more likely to have a diagnosis of dehydration on admission to an
emergency department than adults ages 65-74 years.
Older African American and
Black adults have higher prevalence rates of dehydration on hospitalization
than Caucasian adults (Lancaster, Smiciklas -Wright, Heller, Ahern, &
Jensen, 2003; Warren et al., 1994).
Female gender has been associated with risk
for dehydration in nursing home residents ( Lavizzo-Mourey et al., 1988);
however, male hospitalized patients had an increased risk for dehydration
(Warren et al., 1994) and more recently, no gender differences were detected in
a large database study (Xiao et al., 2004).
In general, individuals in long-term care (LTC) settings are
considered to be at increased risk, with one-third of residents experiencing a
dehydration episode in a 6-month period (Mentes, 2006).The following discussion will highlight at risk
groups of patients, hydration habits, and clinical parameters that indicate
risk.
Populations
Several groups of patients, based on medical diagnosis, are at
increased risk. These groups include chronic mentally ill, surgical, stroke,
and end-of-life patients.
Chronic Mentally Il Patients
Special consideration should be given to chronic mentally ill older
adults (eg, individuals with schizophrenia, bipolar disorder,
obsessive-compulsive disorder) because they may be at risk for hydration
problems.
heir antipsychotic medications may blunt their thirst response and
put them at increased risk in hot weather for dehydration and heat stroke (
Batscha , 1997).
In addition, even small increases in their antipsychotic
medications may predispose them to neuroleptic malignant syndrome (NMS), of which
hyperthermia and dehydration are prominent features (Bristow & Kohen, 1996;
Jacobs, 1996; Sachdev, Mason, & Hadzi- Pavlovic , 1997 ).
In these
individuals, risks for over-hydration stem from a combination of the drying
side effects of prescribed psychotropic medications and the individual’s
compulsive behaviors that result in excessive fluid intake ( Cosgray ,
Davidhizar , Giger, &Kreisl , 1993).
Patients Suffering With Stroke
There is increasing evidence that dehydration may play an important
part in contributing to early cerebral ischemia (Rodriguez et al., 2009), and
in the early recovery from stroke (Kelly et al., 2004).
In fact, Kelly et al.
(2004) found that dehydration in patients with stroke was hospital acquired and
led to poorer outcomes for recovering patients with stroke. Dehydration,
signified by increased serum osmolality, led to a 2.8- to 4.7-fold increase in
the risk of hospitalized patients with stroke acquiring a venous
thromboembolism (VTE).
Hospitalized patients recovering from stroke should be carefully
and continuously monitored for dehydration.
Another sequela of stroke is
dysphagia that can cause dehydration (Whelan, 2001). This appears to be related
not only to the dysphagia resulting from the stroke but also the poor
palatability of the thickened fluids offered to patients to prevent aspiration.
Post Surgery Patients
Prolonged nothing by mouth (NPO) status prior to elective surgery
has been linked to increased risk of dehydration and adverse effects such as
thirst, hunger, irritability, headache, hypovolemia, and hypoglycemia in
surgical patients (Smith, Vallance, & Slater, 1997: Yogendran , Asokumar ,
Cheng, & Chung, 1995).
Crenshaw and Winslow (2002) have found that despite
the formulation of national guidelines developed by the American Society of
Anesthesiologist Task Force on Preoperative Fasting, patients were still being
instructed to fast too long prior to surgery (Crenshaw & Winslow, 2002).
In
fact, patients may safely consume clear liquids up to 2 hours of elective
surgery using general anesthesia, regional anesthesia, or sedation anesthesia.
End of Life Patients
Maintaining or withholding fluids at the end of life remains a
controversial issue. Proponents suggest that dehydration in the terminally ill
patient is not painful and lessens other noxious symptoms of terminal illness,
such as excessive pulmonary secretions, nausea, edema, and pain (dehydration
acts as a natural anesthetic: Fainsinger & Bruera , 1997 ) .
Some suggest
additional benefit from the decreased need to stand up to use the restroom and
receive bedpans or diaper changes, which could be difficult or painful for
someone at the end of life.
Opponents to this position suggest that associated
symptoms of dehydration such as acute confusion and delirium are stressful and
reduce the quality of life for the terminally ill older adult ( Bruera , Belzile
, Watanabe, &Fainsinger , 1996).
Most research that has been done with
terminally ill patients with cancer has examined discomforts of dehydration
including thirst, dry mouth, and agitated delirium.
However, research has not
demonstrated a link between biochemical markers of dehydration and these
various symptoms in terminally ill patients (Burge, 1993; Ellershaw ,
Sutcliffe, & Saunders, 1995; Morita, Tei , Tsunoda , Inoue, &Chihara ,
2001).
It is suggested that several confounding factors influence the uncomfortable
dehydration like symptoms that accompany the end of life. These include use and
dosage of opiates, type and location of cancer, hyperosmolality, stomatitis,
and oral breathing (Morita et al., 2001).
On the other hand, Bruera et al.
(1996) have determined that small amounts of fluids delivered subcutaneously
via hypodermoclysis plus opioid rotation was effective in decreasing delirium
and antipsychotic use and did not cause edema in terminally ill patients.
A
2-day long pilot study of parenteral hydration in terminally ill patients with
cancer led to statistically significant decreases in hallucination, myoclonus,
fatigue, and sedation ( Bruera et al., 2005).
However, research suggests that
artificial hydration does not prolong life ( Bruera et al., 2005; Meier,
Ahronheim , Morris, Baskin-Lyons, & Morrison, 2001; Mitchell, Kiely, &
Lipsitz, 1997).
Therefore, it is recommended that maintaining or withholding fluids
at the end of life be an individual decision that should be based on the
etiology of illness, use of medications, presence of delirium, and family and
patient preferences (Fainsinger & Bruera , 1997 ; Morita et al., 2001;
Schmidlin , 2008).
Schmidlin (2008) recommended early discussions with patients
and families on their wishes as well as educating patients on the current
knowledge about artificial hydration so that proper patient-centered care will
be provided.
Hydration Habits
Hydration habits may indicate level of risk for dehydration in
older adults. Some hydration habits may have developed over a lifetime, and
others are adaptations to current health status. Four major categories of
hydration habits have been identified (Mentes, 2006).
The categories include
those older adults who “can drink,” “cannot drink,” “will not drink,” and older
adults who are at the “end of life.”
`For example, older adults who can drink
are those who are functionally capable of accessing and consuming fluids but
who may not know what is an adequate intake or may forget to drink secondary-
to cognitive impairment.
Older adults who cannot drink are those who are
physically incapable of accessing or safely consuming fluids related to
physical frailty or difficulty swallowing; older adults who will not drink are
those who are capable of consuming fluids safely but who do not.
Because of
concerns about being able to reach the toilet with or without assistance or who
relate that they have never consumed many fluids; and older adults who are
terminally ill comprise the end-of-life category.
Understanding hydration habits
of older adults can help nurses to plan appropriate interventions to improve or
ensure adequate intake (Mentes, 2006).
Indicators of Hydration Status
A priority for nursing, regardless of clinical setting, is the
prevention of dehydration. Unfortunately, many of the standard tests for
detection of dehydration only confirm a diagnosis of dehydration after it is
too late to prevent the episode.
In our fast-paced nursing environments, it is
difficult to monitor the fluid intake of all our older patients.
Although
controversial, the use of urine color and specific gravity has been shown to be
reliable indicators of hydration status (not dehydration) in older individuals
in nursing homes and a Veterans Administration Medical Center with adequate
renal function (Culp, Mentes, & Wakefield, 2003 ; Mentes, Wakefield, &
Culp, 2006).
Specifically, the use of urine color, as measured by a urine color
chart, can be helpful in monitoring hydration status (Armstrong et al., 1994;
Mentes & IVANRC, 2000). The urine color chart has eight standardized colors
ranging from pale straw (number 1) to greenish brown (number 8), approximating
urine-specific gravities of 1.003-1.029 (Armstrong et al., 1994).
The urine
color chart is most effective when an individual’s average urine color is
calculated over several days for an individual referent value.
If the older
person’s urine becomes darker from his or her average color, further assessment
into recent intake and health status can be conducted and fluids can be
adjusted to improve hydration status before dehydration occurs.
Limitations in
using urine indices to estimate specific gravity include
(a) certain
medications and foods can discolor the urine (Mentes, Wakefield et al., 2006;
Wakefield, Mentes, Diggelmann, &Culp, 2002)
(b) persons must be able to
give a urine specimen for a color evaluation
(c) best results in the use
of urine color as an indicator has been documented in older adults with
adequate renal function (Mentes, Wakefield et al., 2006).
Bioelectrical impedance analysis (BIA) is a measurement that has
been used mostly in the fitness industry to estimate body composition,
including body mass index (BMI), TBW, and intracellular and extracellular
water.
Several nursing studies have used impedance measurements to estimate TBW
and intracellular and extracellular water (Culp et al., 2003; Culp et al.,
2004). Although mostly used in research, BIA is a noninvasive, reliable method
to estimate body water (Ritz & Source Study, 2001).
Because TBW is weight
and body composition dependent, this measure is best used after a baseline
value of TBW, intracellular, and extracellular fluid in liters has been
documented. Then, deviations from the individual baseline can be noted.
Salivary osmolality is an emerging clinical indicator of hydration
status, which is sensitive in younger healthy adults (Oliver, Laing, Wilson,
Bilzon , & Walsh, 2008) and has been tested in a same sample of nursing
home residents (Woods & Mentes, 2011 ).
Indicators of dehydration
Dehydration is the loss of body water from intracellular and
interstitial fluid compartments that is associated with hypertonicity (Mange et
al., 1997).
Therefore, the most reliable indicators of dehydration are elevated
serum sodium, serum osmolality, and BUN/creatinine ratio.
The
most common clinical assessments of dehydration include the presence of dry
oral mucous membranes, tongue furrows, decreased saliva, sunken eyes, decreased
urine output, upper body weakness, a rapid pulse (Gross et al., 1992), and
tongue dryness ( Vivanti , Harvey, & Ash, 2010; Vivanti , Harvey, Ash,
&Battistutta , 2008).
Decreased axillary sweat production as a clinical
sign of dehydration has produced contradictory results, making it an unreliable
indicator of dehydration (Eaton, Bannister, Mulley, & Connolly, 1994; Gross
et al., 1992).
Assessment of sternal skin turgor as a sign of dehydration has
been a mainstay in nursing practice: however, it is also an ambiguous indicator
for dehydration in older individuals, with some researchers finding it
unreliable because of age-related changes in skin elasticity(Gross et al.,
1992) and others finding it reliable (Chassagne, Druesne , Capet, Ménard,
&Bercoff , 2006; Vivanti et al., 2008).
Interventions and Care Strategies
A hydration management intervention is an individualized daily plan
to promote adequate hydration based on risk factor identification that is
derived from a comprehensive assessment. The intervention is divided into two
phases: risk identification and hydration management.
Risk Identification
Based on the collected assessment data, a risk appraisal for
hydration problems is completed using the Dehydration Risk Appraisal Checklist.
Hydration Management
Managing fluid intake for optimal fluid balance consists of
(a)
acute management of oral intake
(b) ongoing management of oral intake
Acute Management of Oral Intake
Any individual who develops a fever, vomiting, diarrhea, or a
nonfebrile infection should be closely monitored by implementing intake and
output records and provision of additional fluids as tolerated (Wakefield et
al., 2008; Weinberg et al., 1994).
Individuals who are required to be NPO for
diagnostic tests should be given special consideration to shorten the time that
they must be NPO and should be provided with adequate amounts of fluids and
food when they have completed their tests.
For many procedures, a 2-hour fluid
fast is recommended (”Practice Guidelines for Preoperative Fasting.” 1999).
Any
individual who develops unexplained weight gain, pedal edema, neck vein
distension, or shortness of breath should be evaluated and closely monitored
for overhydration Fluids should be temporarily restricted and the individual’s
primary care provider notified.
Specific attention should be focused on
individuals who have renal disease or congestive heart failure (CHF); however,
Holst, Strömberg , Lindholm, and Willenheimer (2008) found that a liberal fluid
prescription based on body weight could be offered to patients with stable CHF.
Older adults taking selective serotonin reuptake inhibitors (SSRIs) should have
their serum sodium levels and their hydration status monitored carefully
because they are at risk for hyponatremia and increasing fluid intake may
aggravate an evolving hyponatremia ( Movig , Leufkens , Lenderink ,
&Egberts , 1992 ) .
Ongoing Management of Oral Intake
Ongoing management of oral intake consists of the following five
components:
1. Calculate a daily fluid goal.
All older adults should have an individualized fluid goal
determined by a documented standard for daily fluid intake.
There is
preliminary evidence that the standard suggested by Skipper (1993) of 100 ml/kg
for the first 10 kg of weight, 50 ml/kg for the next 10 kg, and 15 ml/kg for
the remaining kilogram is preferred ( Chidester &Spangler , 1997).
Because this standard
reflects fluid from all sources, to calculate a standard for fluids alone, 75%
of the total calculated from the formula can be used.
This formula allows for
at least 1,500 ml of fluid per day as a minimum, which has been shown to be
well tolerated in older men aged 55-75 years ( Spigt , Knottnerus , Westerterp
, Olde Rikkert , &Schayck , 2006).
Other Standards Include the Following
1.1,600 ml/m² of body surface per day (Gaspar, 1988; Butler &
Talbot, 1944); more recently, Gaspar (1999) recommended 75% of this standard
30 ml/kg body weight with 1,500 ml/day minimum (Chernoff, 1994) I
ml/kcal fluid for adults (National Research Council, 1989)
1,600 ml/day (Hodgkinson, Evans, & Wood, 2003)
2. Compare individual’s current intake to the amount calculated
from applying the standard to evaluate the individual’s hydration status.
3. Provide fluids consistently throughout the day (Hodgkinson et
al., 2003).
a. Plan fluid intake as follows: 75%-80% delivered at meals and
20%-25% delivered during non-meal times, such as medication times and planned
nourishment times (Simmons et al., 2001).
b. Offer a variety of fluids, keeping in mind the individual’s
previous intake pattern (Zembrzuski, 1997). Alcoholic beverages, which exert a
diuretic effect, should not be counted toward the fluid goal.
Caffeinated
beverages may be counted toward the fluid goal based on individual assessment
because there is evidence that in individuals who are regular users, there are
no untoward effects on fluid balance and that recommendations to refrain from
moderate amounts of caffeinated beverages (250-300 mg, equivalent of two to three
cups of coffee or five to eight cups of tea may adversely affect fluid balance
in older adults (Maughan & Griffin, 2003).
c. Fluid with medication
administrations should be standardized to a prescribed amount (eg, at least 180
ml or 6 oz.) per administration time.
4. Plan for at-risk individuals for those who are at risk of
underhydration because of poor intake, the following strategies can be
implemented based on time, setting, and formal or informal caregiver issues:
a. Fluid rounds mid-morning and late afternoon, where caregiver
provides additional fluids (Robinson &Rosher , 2002).
b. Provide 2- to
8-oz. glasses of fluid in morning and evening (Robinson &Rosher , 2002).
c.
“Happy hours” in the afternoon, where patients can gather together for
additional fluids and socialization (Musson et al., 1990).
d.“Tea time” in
the afternoon, where patients come together for fluids, nourishment, and
socialization (Mueller &Boisen , 1989).
e. Use of modified fluid containers based on intake behaviors (eg,
ability to hold cup and swallow, Mueller &Boisen , 1989).
f . Offer a variety
of fluids and encourage ongoing intake throughout the day for those with
cognitive impairment. Offer fluids that the person prefers (Simmons et al., 2001).
g. Offer encouragement to drink. family involvement in and support, and
coordination of staff communication about hydration issues (Mentes, Chang et
al., 2006).
5. Fluid regulation and documentation
a. Individuals who are
cognitively intact, visually capable, and have adequate renal function can be
taught how to regulate their intake through the use of a color chart to compare
to the color of their urine (Armstrong et al., 1994; Armstrong et al., 1998;
Mentes, Wakefield et al., 2006).
For those individuals who are cognitively
impaired, caregivers can be taught how to use the color chart.
b. Frequency of documentation of fluid intake will vary from
setting to setting and is dependent on an individual’s condition. However, in
most settings, at least one accurate intake and output recording should be
documented and should include the amount of fluid consumed, intake pattern,
difficulties with consumption, and a urine specific gravity and color (Mentes
& IVANRC, 2000).
c. Accurate calculation of intake requires knowledge of the volumes
of containers used to serve fluids, which should be posted in a prominent place
on the care unit, because a study by Burns (1992) suggested that nurses
overestimated or underestimated the volumes of common vessels.
Evaluation Outcomes
Adherence to the hydration management guideline can be monitored by
the frequency of monitoring (to be determined by setting), as follows:
Urine-specific gravity checks, preferably a morning specimen
(Armstrong et al., 1994; Armstrong et al., 1998; Hodgkinson et al., 2003;
Wakefield et al., 2002). A value greater than or equal to 1,020 implies an
underhydrated state and requires further monitoring ( Kavouras , 2002; Mentes,
2006).
Urine color chart monitoring, preferably a morning specimen
(Armstrong et al., 1994; Armstrong et al., 1998; Wakefield et al., 2002).
24-hour intake recording (output recording may be added; however,
in settings where individuals are incontinent of urine, an intake recording
should suffice; Hodgkinson et al., 2003)
Expected improved health outcomes of consistent application of a
hydration management plan include the following:
Maintenance of body hydration (Mentes & Culp, 2003; Robinson
&Rosher , 2002; Simmons et al., 2001) Decreased infections, especially
urinary tract infections (McConnell, 1984;
Mentes & Culp, 2003; Robinson &Rosher , 2002) Improvement
in urinary incontinence (Hart &Adamek , 1984; Spangler et al., 1984)
Lowered urinary pH (Hart &Adamek , 1984)
Decreased constipation (Robinson &Rosher , 2002) Decreased
acute confusion (Mentes & Culp. 2003; Mentes et al., 1999)