- Email: [email protected]
Dehydration: Hazards and Benefits
CE Article Instructions to CE enrollees: The closed-book, multiple-choice examination that follows this article is designed to test your understanding of the educational objectives listed below. The answer form is on the inside back cover. On completion of this article, the reader should be able to: 1. Discuss the clinical significance of dehydration 2. Identify preventive methods for dehydration 3. Describe beneficial situations for dehydration
Dehydration: Hazards and Benefits Jill A. Bennett, PhD, RN
Abstract: Dehydration is a serious risk for elders because total body water decreases with age, aging kidneys are less able to concentrate urine, and the sensation of thirst decreases. Geriatric nurses traditionally have assessed for dehydration, but its signs are difficult to detect in many patients. Instead, nurses, assistive personnel, and family members must work to prevent dehydration in elders. In contrast, dehydration may be beneficial to patients during the final stage of a terminal illness, although the decision to withhold or withdraw medical hydration may present a legal and ethical dilemma for nurses. (Geriatr Nurs 2000;21:84-7)
D
ehydration is a common condition among elders, whether they live in the community or in long-term care (LTC) facilities. In 1991, dehydration was one of the 10 diagnoses most frequently reported for Medicare hospitalizations.1 Individuals older than 85 are particularly susceptible to dehydration.2,3 The purpose of this article is to report current research findings that show that many of the traditional signs geriatric nurses use to assess hydration may not be helpful indicators in elderly patients. Ideas will be presented to prevent dehydration in elders during the course of nursing care without waiting for symptoms to trigger action. Finally, an update of the current thinking on the benefits and ethics of dehydration during the end stage of terminal illness will be presented.
THE SIGNIFICANCE OF DEHYDRATION TO ELDERS AND SOCIETY Dehydration causes not only physical distress to individuals but also enormous costs to the health care system. Approximately 1 million elderly individuals per year are admitted to acute care hospitals with isotonic dehydration as a major component of their clinical presentation.4 In 1991, patients older than 65 who had a primary diagnosis of dehydration accumulated 1,853,000 hospital days, the cost of which can be estimated from Medicare’s average cost per day of $625 for a total 1-year hospitalization cost of nearly $1.2 billion.5 Health care providers agree that inadequate fluid intake has severe consequences for elderly pa-
84
Geriatric Nursing 2000 • Volume 21 • Number 2
tients. For example, researchers using data from the 1991 Medicare Provider Analysis and Review files found that 18% of people older than 65 who were hospitalized with a principal diagnosis of dehydration died within 30 days of hospitalization and an additional 30.6% died within 1 year.1 Even if dehydrated patients don’t die, inadequate fluid intake can have serious medical consequences, such as urinary tract infections, bowel obstructions, delirium, and cardiovascular symptoms.
WHY ELDERS BECOME DEHYDRATED Total body water decreases with age. Whereas approximately 80% of a child’s weight is water, the total body water of an adult age 61 to 74 is approximately 43.4% for women and 50.8% for men.6,7 Thus, even small decreases in fluid intake can cause proportionately more dehydration in an older adult than in a younger person. As people age, the concentrating ability of aging kidneys declines so that, even when elders are deprived of water, urine flows are not significantly reduced, which increases the likelihood of dehydration.7 The physiological mechanism for this failure to concentrate urine, even in the presence of water deprivation, is unclear, and researchers do not agree on its cause. Some believe the condition is a result of reduced plasma vasopressin,8 although others argue that vasopressin levels are the same in older adults but renal changes with age prevent the normal response to them.3 In addition, thirst decreases as a person ages, resulting in the loss of an important self-regulating defense against dehydration. For example, elderly men in one study3 age 67 to 75 and young healthy men age 20 to 31 were deprived of water for 24 hours and then allowed to drink as much water as they wanted for an hour. Because they were not as thirsty, the older men did not drink enough water to dilute their plasma and urine to normal levels, but the young men did. Other factors that make an elderly individual prone to dehydration include multiple medications, especially diuretics,2 excessive use of sedatives, antipsychotics, tranquilizers, and even nonsteroidal antiinflammatory drugs.4 In addition, dementia, alcohol abuse,4 incontinence, and lack of mobility are risk factors for dehydration in elders.9,10
NURSING HOME RESIDENTS ESPECIALLY SUSCEPTIBLE TO DEHYDRATION The incidence of dehydration among residents of LTC facilities is difficult to determine because unrecorded dehydration may underlie the medical conditions listed as the causes for hospital admissions or deaths. Although research is difficult and studies are scarce, dehydration generally is thought common in nursing homes. In a study of fluid intake by Canadian
Geriatric Nursing 2000 • Volume 21 • Number 2
nursing home residents, a researcher observed that all 57 patients received inadequate fluids (mean intake = 1141 mL) based on a standard of 2 to 2.5 L per day.9 In another study, a researcher found that 52% of 40 nursing home residents were below a daily standard of 30 mL of water per kilogram of body weight.11 These findings affirm the belief that dehydration may be common in nursing homes and that inadequate fluid intake may be a primary cause. Some authors recommend 1 mL of fluid for every kcal of energy consumed. However, keeping track of food in order to calculate this requirement is not practical, and this standard does not account for elders who may eat very little and thus need higher proportions of liquids. Another standard—30 mL per kg of body weight per day—may not be useful for obese elders or small frail elders. A more complex standard based on weight recommends 100 mL fluid/kg for the first 10 kg, 50 mL for the next 10 kg, and 15 mL for the remaining kg, but this standard would require a separate calculation for each individual, even if body weights were easily available. Therefore, most authors recommend a simple standard for all adults—1500 mL/day of oral fluids in addition to food. No conclusive evidence exists that elders need less daily fluid than do young adults.9,11-14
THE ROLE OF GERIATRIC NURSES Assess for Signs of Dehydration The clinical signs of dehydration can be difficult to identify, especially when fluid intake is inadequate but dehydration is not yet acute. Many of the traditional clinical signs of dehydration in younger patients may be caused by other factors in elderly patients. A study that compared a list of clinical signs in elderly emergency department (ED) patients who were diagnosed with acute dehydration concluded that oral symptoms, such as tongue furrows and dry mucous membranes, were the most indicative clinical indicators of dehydration. 15 However, these oral symptoms may be misleading when used to detect dehydration in elders because medication and mouth-breathing also can cause oral dryness.16 Similarly, constipation, although a symptom of dehydration, can be caused by medications. Some researchers suggest a weight loss of greater than 3% in elders is a sign of dehydration.16 On the other hand, weight loss also has been shown to result from the use of liquid supplements in lieu of food17 or from malnutrition or illness. Although several nursing articles suggest testing skin turgor on the forehead to increase accuracy, researchers testing dehydrated elderly patients in the hospital found that skin turgor, whether assessed on the forearm, forehead, or sternum, had only a weak correlation with dehydration.15Axillary sweating also has been suggested as a clinical indicator of hydration status,18
85
Table 1 Dehydration Signs • Constipation • Disorientation • Dry mucous membranes • Orthostatic hypotension • Weight loss
Table 2 The Dehydration Prevention Mantra for Geriatric Nurses Water, water, water! Milk, juices, and non-salty soups for variety. Decrease coffee, tea, colas, and liquid diet supplements because they may create dehydration.
but other researchers have found that lack of axillary sweating was not associated with dehydration.15 Orthostatic hypotension often is named as a dehydration sign but, again, this may not be a useful indicator in elders because prolonged bedrest, medications, and chronic illnesses also cause orthostatic hypotension.16,19 In ED patients, researchers found that orthostatic hypotension did not distinguish between levels of dehydration severity in elderly subjects.15 The difficulty of obtaining accurate orthostatic blood pressure measurements in debilitated patients may be a reason for the weak associations between this measure and dehydration. 15,19 Urine concentration often is used by nurses as a sign of dehydration, but urine specific gravity is poorly correlated with serum biochemical parameters of dehydration.16 If serum laboratory values are available, the best indicators of dehydration are serum osmolality greater than 300, serum sodium greater than 145, blood urea nitrogen (BUN) more than 20, or BUN:creatinine greater than 20:1.15,20 When assessing elderly patients, a geriatric nurse should be aware that clinical signs may not appear until dehydration is far advanced. In addition, the usual signs, listed in Table 1, may be caused by other factors. However, if several of these clinical indicators appear together or are a change from an elder’s baseline, dehydration may be the cause. Prevent Dehydration Rather than waiting for symptoms of severe dehydration to appear, it is critically important for nurses to prevent dehydration by ensuring adequate fluid intake
86
in elderly patients. All liquids are not equally good for maintaining fluid balance. Water, of course, is the best liquid to replenish body water and should be at least half the daily intake of fluid. Milk is also good but may thicken phlegm or cause constipation. Fruit and vegetable juices are nutritious and useful for providing variety in daily liquids. Likewise, soups can be nutritious but may be too salty. Fluids that are not useful for preventing dehydration are soft drinks, coffee, tea, and alcohol. Although consuming reasonable amounts of these is not harmful, they can cause a person to lose fluid because of the kidneys’ reaction to sugars and diuretics. Table 2 outlines a “mantra” for geriatric nurses. The geriatric nurse is responsible for preventing dehydration in elderly patients, but prevention actually may occur through training and supervising assistive personnel or teaching family members to encourage increased fluid intake. If nursing assistants and nurses work as a team to devise interventions, they may spare patients the consequences of dehydration by preventing it before it starts. Likewise, for elders who live at home, dehydration may be prevented by making family members or caregivers aware of the importance of having liquids readily available. Some strategies for preventing dehydration are shown in Table 3.
DEHYDRATION IN TERMINAL ILLNESS In some patients who are terminally ill, dehydration may be beneficial by causing a mild euphoria. However, withholding medical nutrition and hydration is a difficult issue for many nurses and physicians, perhaps because offering food and drink is emotionally linked to sustaining life and providing patient care. Although eating and drinking indeed have symbolic meanings, artificial hydration and nutrition by means of feeding tubes and intravenous feedings may not have the same meaning to patients. Legal consensus developed over the past 2 decades holds that competent patients have a right to refuse treatments, including tube-feeding. In the case of incompetent patients, surrogates may decline treatment on their behalf. These rights are supported by both court decisions and law.23 Because nurses have a professional obligation to respect a patient’s wishes, the legal aspects of withholding medical hydration are clear: if a patient desires to discontinue treatment, the nurse should act as the patient’s advocate to secure compliance by the medical team. The ethical issues are more thorny. The manner in which the decision to discontinue medical hydration is approached by the patient and family members may be, in part, a result of information conveyed by the nurse. Therefore, nurses who care for dying elderly patients should grapple with their own beliefs, ethics, and atti-
Geriatric Nursing 2000 • Volume 21 • Number 2
Table 3 Dehydration Prevention for Elders Aim for 1500 mL of oral liquids per day for each patient unless he or she has special medical conditions, such as congestive heart failure. Allow adequate time for eating or feeding at mealtimes. Meals can provide two-thirds of daily fluids if patients are encouraged to consume liquids and have time to do so. Encourage family members to participate in feeding and teach them to encourage consumption of both liquids and food. Accommodate patient preferences for particular liquids during or between meals whenever possible. On meal trays, open all containers, pour liquids into cups or provide straws, depending on individual needs. Provide water that is available all day at bedside or chairside. Pitchers and cups must be within reach and not too heavy to be easily handled by an elderly individual alone. Offer fluids regularly during the day. Patients who don’t think to serve themselves may consume liquids when they are offered as part of a snack of other regular routine.1 Encourage consumption of fluids with medications. One study showed that liquids consumed with medications made the difference between adequate and inadequate daily fluid intake for some patients.2 Pay particular attention to patients who are not mobile or are restrained. One researcher reported observing a woman in a wheelchair who called repeatedly for something to drink and attempted to reach the water on her bedside stand. Although she was in a vest restraint, the resident slipped to the floor. The nurse put her back in her chair and tightened her restraint but did not give her a drink of water.3 1. Kositzke JA. A question of balance: dehydration in the elderly. J Geron Nurs 1990;16:4-11. 2. Chidester JC, Spangler AA. Fluid intake in the institutionalized elderly. J Am Diet Assoc 1997;97:23-30. 3. Kayser-Jones J. Influence of the environment on falls in nursing homes: a conceptual model. In: Katz PR, Kane RL, Mezey MD, editors. Advances in long-term care. New York: Springer; 1993 p. 177-95.
nutrition, a phenomenon that has been observed in rats.26 Nurses and family members may be afraid that the decision to withhold medical hydration and nutrition may cause the patient to feel hungry and thirsty. Although this subject is difficult to research, a recent study monitored 32 terminally ill patients and found that 20 patients (63%) never experienced hunger and an additional 11 patients (34%) felt hunger only initially. Similarly, 62% experienced no thirst or were thirsty only initially. In all patients, hunger or thirst symptoms were alleviated with small amounts of food, liquid, or ice chips.27 Another author suggests that the sensation of thirst in dying patients may be caused by dry mouth rather than thirst and can be relieved by ice chips or frequent sips of cold water.24 Nurses who care for dying patients will have to face each situation by helping patients and families weigh the benefits of discontinuing medical hydration. Death then may occur with less pain and fewer barriers, such as intravenous lines and feeding tubes, that may be uncomfortable to the patient and keep family members from close physical contact.
DEHYDRATION AND GERIATRIC NURSES Some nurses, especially those who work in nursing homes, put a lot of energy into preventing dehydration in elderly patients by developing protocols, suggesting changes in routines, educating family members, and motivating nursing assistants. Nurses who care for terminally ill patients have to work equally hard to overcome emotions and traditional ideas that food, love, and artificial nutrition and hydration are equal. In some cases, nurses will help patients and families choose dehydration for a dying patient, and the nurse will be required to advocate for the implementation of that decision. Although dehydration may be a different issue for each patient, a geriatric nurse’s professional practice requires a constant awareness of the importance of hydration status to an elderly patient’s quality of life. REFERENCES
tudes about discontinuing artificial hydration in a patient’s final days. The literature contains some evidence that withholding artificial nutrition and hydration at the end of life actually may reduce pain. Some physicians and nurses report observing patients who were not hydrated and had more comfortable deaths than those who were medically hydrated.24,25 Although research is needed to define the etiology of dehydration’s possible analgesic effects, it has been suggested that the increased production of ketones during calorie deprivation may cause a partial loss of sensation. Another possibility is that opioid peptides may be released in a state of advanced mal-
Geriatric Nursing 2000 • Volume 21 • Number 2
1. Warren JL, Bacon WE, Harris T, McBean AM, Foley DJ, Phillips C. The burden and outcomes associated with dehydration among U.S. elderly, 1991. Am J Public Health 1994;84:1265-9. 2. Lavizzo-Mourey RJ, Johnson J, Stolley P. Risk factors for dehydration among elderly nursing home residents. J Am Geriatr Soc 1988;36:213-8. 3. Phillips PA, Rolls BJ, Ledingham JG, et al. Reduced thirst after water deprivation in healthy elderly men. N Engl J Med 1984; 311:753-9. 4. Sansevero AC. Dehydration in the elderly: strategies for prevention and management. Nurse Practitioner 1997;22:41-57. 5. Weinberg AD, Pals JK, McGlinchey-Berroth R, Minaker KL. Indices of dehydration among frail nursing home patients: highly variable but stable over time. J Am Geriatr Soc 1994;42: 1070-3. 6. Miller CA. Nursing care of older adults. Glenview (IL): Scott, Foresman and Co.; 1990. 7. Lavizzo-Mourey RJ. Dehydration in the elderly: a short review. J Natl Med Assoc 1987;79:1033-8. 8. Yamamoto T, Harada H, Fukuyama J, Hayashi T, Mori I. Impaired arginine-vasopressin secretion associated with hypoangiotensinemia in hypernatremic dehydrated elderly patients. JAMA 1988;259: 1039-42.
87
CE
9. Armstrong-Esther CA, Browne KD, ArmstrongEsther DC, Sander L. The institutionalized elderly: dry to the bone! Int J Nurs Studies 1996;33:619-28. 10. Colling JC, Owen TR, McCreedy MR. Urine volumes and voiding patterns among incontinent nursing home residents. Residents at highest risk for dehydration are often the most difficult to track. Geriatr Nurs 1994;15:188-92. 11. Chidester JC, Spangler AA. Fluid intake in the institutionalized elderly. J Am Diet Assoc 1997;97:23-30. 12. Reedy DF. How can you prevent dehydration? Geriatr Nurs 1988;9:224-6. 13. Kositzke JA. A question of balance: dehydration in the elderly. J Geron Nurs 1990;16:4-11. 14. Hoffman NB. Dehydration in the elderly: insidious and manageable. Geriatrics 1991;46:35-8. 15. Gross CR, Lindquist RD, Woolley AC, Granieri R, Allard K, Webster B. Clinical indicators of dehydration severity in elderly patients. J Emerg Med 1992;10:267-74. 16.Weinberg AD, Minaker KL, Council on Scientific Affairs AMA. Dehydration, evaluation and
management in older adults. JAMA 1995;274: 1552-6. 17. Kayser-Jones J, Schell E. The effect of staffing on the quality of care at mealtime. Nurs Outlook 1997;45:64-72. 18. Eaton D, Bannister P, Mulley GP, Connolly MJ. Axillary sweating in clinical assessment of dehydration in ill elderly patients. Br Med J 1994;308:1271. 19. Wandel JC. The use of postural vital signs in the assessment of fluid volume status. J Prof Nursing 1990;6:46-54. 20. Himmelstein DU, Jones AA, Woolhandler S. Hypernatremic dehydration in nursing home patients: an indicator of neglect. J Am Geriatr Soc 1983;31:466-71. 21. Kayser-Jones J, Schell ES. Staffing and the mealtime experience of nursing home residents on a special care unit.Am J Alz Dis 1997;12(2):67-71. 22. Kayser-Jones J. Influence of the environment on falls in nursing homes: a conceptual model. In: Katz PR, Kane RL, Mezey MD, editors. Advances in long-term care. New York: Springer; 1993 p. 177-95.
23. Meisel A. Barriers to forgoing nutrition and hydration in nursing homes. Am J Law Med 1995;21:335-82. 24. Printz LA. Terminal dehydration, a compassionate treatment. Arch Intern Med 1992;152:697700. 25. Taylor M. Benefits of dehydration in terminally ill patients. Geriatr Nurs 1995;16:271-2. 26. Printz LA. Is withholding hydration a valid comfort measure in the terminally ill? Geriatrics 1988;43:84-8. 27. McCann RM, Hall WJ, Groth-Juncker A. Comfort care for terminally ill patients. The appropriate use of nutrition and hydration. JAMA 1994;272: 1263-6.
JILL A. BENNETT, PhD, RN, is an assistant professor in the School of Nursing at San Diego State University. Copyright © 2000 by Mosby, Inc. 0197-4572/2000/$8.00 + 0
34/1/107135
Test I.D. No.: G107135 Contact hours: 1.0 Processing fee: $9 Passing score: 70% (seven correct answers)
1. Without adequate hydration, the following medical consequences were listed EXCEPT: A. Delirium B. Pulmonary hypertension C. Cardiovascular symptoms D. Urinary tract infection
5. Which of the following is not recommended to prevent dehydration? A. Fruit and fruit juices B. Coffee C. Soup D. Water
9. Which of the following would be the best to combat dehydration in the elderly? A. Juices B. Soda C. Caffeine D. Liquid diet supplements
2. Factors that may influence the elderly to be more dehydrated include the following EXCEPT: A. Failure to concentrate urine B. Decreased thirst C. Use of other medications D. Lack of supervision and encouragement
6. What are the alleged analgesic effects of dehydration? A. Increased production of ketones that decrease sensation B. Release of opioids C. A and B D. Neither A nor B
10. Besides offering fluids regularly, what else can be done to keep an elderly client hydrated? A. Increase bowel and bladder training B. Encourage fluid intake with medications C. Offer only room temperature fluids D. Refrain from offering fluids after 8 PM to limit nocturnal incontinence
3. What is the most common standard for daily fluid intake? A. 2 to 2.5 L/day B. 1.5 to 2.0 L/day C. 1.5 L/day D. 500 mL/day
7. Orthostatic hypotension as an indicator of dehydration may be complicated by: A. Patients’ debilitated condition B. Medications or chronic illness C. Prolonged bed rest D. All of the above
4. What is the best indicator of dehydration? A. Serum osmolality greater than 300 B. Orthostatic hypotension C. Skin turgor D. Oral symptoms
8. Which of the following is another good indicator of dehydration? A. Serum osmolality less than 300 B. BUN greater than 20 C. BUN:creatinine 10:1 D. Serum sodium greater than 145
88
Geriatric Nursing 2000 • Volume 21 • Number 2
CE ANSWER/ENROLLMENT FORM To receive continuing education credit for any test in this issue, simply do the following: 1. Read the article. 2. Take the test for the article and record your answers on the form below. (You may make copies of the answer form.) You should complete one answer form for EACH test. 3. Mail the completed answer/enrollment form along with a check or money order. Payment must be included for your examination to be processed. 4. The deadline for submitting your answer/enrollment form is 2 years from the date of this issue. 5. Your results will be sent within 4 weeks after your answer form is received. Enrollees who have a passing score will receive a certificate. Instructions: Mark your answers clearly by placing an “x” in the box next to the correct answer. This is a standard form; use only the number of spaces required for the test you are taking. Test I.D. No. 1. ❑ A ❑B ❑C ❑D
2. ❑ A ❑B ❑C ❑D
3. ❑ A ❑B ❑C ❑D
4. ❑ A ❑B ❑C ❑D
5. ❑ A ❑B ❑C ❑D
6. ❑ A ❑B ❑C ❑D
7. ❑ A ❑B ❑C ❑D
11. ❑ A ❑B ❑C ❑D
12. ❑ A ❑B ❑C ❑D
13. ❑ A ❑B ❑C ❑D
14. ❑ A ❑B ❑C ❑D
15. ❑ A ❑B ❑C ❑D
16. ❑ A ❑B ❑C ❑D
17. ❑ A ❑B ❑C ❑D
Name
8. ❑ A ❑B ❑C ❑D
9. ❑ A 10. ❑ A ❑B ❑B ❑C ❑C ❑D ❑D
18. ❑ A 19. ❑ A 20. ❑ A ❑B ❑B ❑B ❑C ❑C ❑C ❑D ❑D ❑D
Credentials
Address
City
State
ZIP
Soc. Sec. No.
Phone
License: State/No. Mail to: Buchanan & Associates 1666 Garnet Ave., Suite 102 San Diego, CA 92109 For more information call: (800) 929-1233 Buchanan and Associates is an approved provider of continuing education in nursing by the American Nurses Credentialing Center Commission on Accreditation.
PROGRAM EVALUATION Strongly agree The objectives of the program were met. 1— The content was appropriate. 1— My expectations have been met. 1— This form of CE is worthwhile. 1— The level of difficulty of this test was: 1— Easy
2— 2— 2— 2— 2—
How long did this program take to complete?
3— 3— 3— 3— 3—
Strongly Disagree 4— 5— 4— 5— 4— 5— 4— 5— 4— 5— Difficult hours
❑ I have enclosed an additional $10 for rush processing. ❑ I have enclosed an additional $15 for foreign delivery.
Geriatric Nursing 2000 • Volume 21 • Number 2
83
Dehydration: Hazards and Benefits Jill A. Bennett, PhD, RN
Abstract: Dehydration is a serious risk for elders because total body water decreases with age, aging kidneys are less able to concentrate urine, and the sensation of thirst decreases. Geriatric nurses traditionally have assessed for dehydration, but its signs are difficult to detect in many patients. Instead, nurses, assistive personnel, and family members must work to prevent dehydration in elders. In contrast, dehydration may be beneficial to patients during the final stage of a terminal illness, although the decision to withhold or withdraw medical hydration may present a legal and ethical dilemma for nurses. (Geriatr Nurs 2000;21:84-7)
D
ehydration is a common condition among elders, whether they live in the community or in long-term care (LTC) facilities. In 1991, dehydration was one of the 10 diagnoses most frequently reported for Medicare hospitalizations.1 Individuals older than 85 are particularly susceptible to dehydration.2,3 The purpose of this article is to report current research findings that show that many of the traditional signs geriatric nurses use to assess hydration may not be helpful indicators in elderly patients. Ideas will be presented to prevent dehydration in elders during the course of nursing care without waiting for symptoms to trigger action. Finally, an update of the current thinking on the benefits and ethics of dehydration during the end stage of terminal illness will be presented.
THE SIGNIFICANCE OF DEHYDRATION TO ELDERS AND SOCIETY Dehydration causes not only physical distress to individuals but also enormous costs to the health care system. Approximately 1 million elderly individuals per year are admitted to acute care hospitals with isotonic dehydration as a major component of their clinical presentation.4 In 1991, patients older than 65 who had a primary diagnosis of dehydration accumulated 1,853,000 hospital days, the cost of which can be estimated from Medicare’s average cost per day of $625 for a total 1-year hospitalization cost of nearly $1.2 billion.5 Health care providers agree that inadequate fluid intake has severe consequences for elderly pa-
84
Geriatric Nursing 2000 • Volume 21 • Number 2
tients. For example, researchers using data from the 1991 Medicare Provider Analysis and Review files found that 18% of people older than 65 who were hospitalized with a principal diagnosis of dehydration died within 30 days of hospitalization and an additional 30.6% died within 1 year.1 Even if dehydrated patients don’t die, inadequate fluid intake can have serious medical consequences, such as urinary tract infections, bowel obstructions, delirium, and cardiovascular symptoms.
WHY ELDERS BECOME DEHYDRATED Total body water decreases with age. Whereas approximately 80% of a child’s weight is water, the total body water of an adult age 61 to 74 is approximately 43.4% for women and 50.8% for men.6,7 Thus, even small decreases in fluid intake can cause proportionately more dehydration in an older adult than in a younger person. As people age, the concentrating ability of aging kidneys declines so that, even when elders are deprived of water, urine flows are not significantly reduced, which increases the likelihood of dehydration.7 The physiological mechanism for this failure to concentrate urine, even in the presence of water deprivation, is unclear, and researchers do not agree on its cause. Some believe the condition is a result of reduced plasma vasopressin,8 although others argue that vasopressin levels are the same in older adults but renal changes with age prevent the normal response to them.3 In addition, thirst decreases as a person ages, resulting in the loss of an important self-regulating defense against dehydration. For example, elderly men in one study3 age 67 to 75 and young healthy men age 20 to 31 were deprived of water for 24 hours and then allowed to drink as much water as they wanted for an hour. Because they were not as thirsty, the older men did not drink enough water to dilute their plasma and urine to normal levels, but the young men did. Other factors that make an elderly individual prone to dehydration include multiple medications, especially diuretics,2 excessive use of sedatives, antipsychotics, tranquilizers, and even nonsteroidal antiinflammatory drugs.4 In addition, dementia, alcohol abuse,4 incontinence, and lack of mobility are risk factors for dehydration in elders.9,10
NURSING HOME RESIDENTS ESPECIALLY SUSCEPTIBLE TO DEHYDRATION The incidence of dehydration among residents of LTC facilities is difficult to determine because unrecorded dehydration may underlie the medical conditions listed as the causes for hospital admissions or deaths. Although research is difficult and studies are scarce, dehydration generally is thought common in nursing homes. In a study of fluid intake by Canadian
Geriatric Nursing 2000 • Volume 21 • Number 2
nursing home residents, a researcher observed that all 57 patients received inadequate fluids (mean intake = 1141 mL) based on a standard of 2 to 2.5 L per day.9 In another study, a researcher found that 52% of 40 nursing home residents were below a daily standard of 30 mL of water per kilogram of body weight.11 These findings affirm the belief that dehydration may be common in nursing homes and that inadequate fluid intake may be a primary cause. Some authors recommend 1 mL of fluid for every kcal of energy consumed. However, keeping track of food in order to calculate this requirement is not practical, and this standard does not account for elders who may eat very little and thus need higher proportions of liquids. Another standard—30 mL per kg of body weight per day—may not be useful for obese elders or small frail elders. A more complex standard based on weight recommends 100 mL fluid/kg for the first 10 kg, 50 mL for the next 10 kg, and 15 mL for the remaining kg, but this standard would require a separate calculation for each individual, even if body weights were easily available. Therefore, most authors recommend a simple standard for all adults—1500 mL/day of oral fluids in addition to food. No conclusive evidence exists that elders need less daily fluid than do young adults.9,11-14
THE ROLE OF GERIATRIC NURSES Assess for Signs of Dehydration The clinical signs of dehydration can be difficult to identify, especially when fluid intake is inadequate but dehydration is not yet acute. Many of the traditional clinical signs of dehydration in younger patients may be caused by other factors in elderly patients. A study that compared a list of clinical signs in elderly emergency department (ED) patients who were diagnosed with acute dehydration concluded that oral symptoms, such as tongue furrows and dry mucous membranes, were the most indicative clinical indicators of dehydration. 15 However, these oral symptoms may be misleading when used to detect dehydration in elders because medication and mouth-breathing also can cause oral dryness.16 Similarly, constipation, although a symptom of dehydration, can be caused by medications. Some researchers suggest a weight loss of greater than 3% in elders is a sign of dehydration.16 On the other hand, weight loss also has been shown to result from the use of liquid supplements in lieu of food17 or from malnutrition or illness. Although several nursing articles suggest testing skin turgor on the forehead to increase accuracy, researchers testing dehydrated elderly patients in the hospital found that skin turgor, whether assessed on the forearm, forehead, or sternum, had only a weak correlation with dehydration.15Axillary sweating also has been suggested as a clinical indicator of hydration status,18
85
Table 1 Dehydration Signs • Constipation • Disorientation • Dry mucous membranes • Orthostatic hypotension • Weight loss
Table 2 The Dehydration Prevention Mantra for Geriatric Nurses Water, water, water! Milk, juices, and non-salty soups for variety. Decrease coffee, tea, colas, and liquid diet supplements because they may create dehydration.
but other researchers have found that lack of axillary sweating was not associated with dehydration.15 Orthostatic hypotension often is named as a dehydration sign but, again, this may not be a useful indicator in elders because prolonged bedrest, medications, and chronic illnesses also cause orthostatic hypotension.16,19 In ED patients, researchers found that orthostatic hypotension did not distinguish between levels of dehydration severity in elderly subjects.15 The difficulty of obtaining accurate orthostatic blood pressure measurements in debilitated patients may be a reason for the weak associations between this measure and dehydration. 15,19 Urine concentration often is used by nurses as a sign of dehydration, but urine specific gravity is poorly correlated with serum biochemical parameters of dehydration.16 If serum laboratory values are available, the best indicators of dehydration are serum osmolality greater than 300, serum sodium greater than 145, blood urea nitrogen (BUN) more than 20, or BUN:creatinine greater than 20:1.15,20 When assessing elderly patients, a geriatric nurse should be aware that clinical signs may not appear until dehydration is far advanced. In addition, the usual signs, listed in Table 1, may be caused by other factors. However, if several of these clinical indicators appear together or are a change from an elder’s baseline, dehydration may be the cause. Prevent Dehydration Rather than waiting for symptoms of severe dehydration to appear, it is critically important for nurses to prevent dehydration by ensuring adequate fluid intake
86
in elderly patients. All liquids are not equally good for maintaining fluid balance. Water, of course, is the best liquid to replenish body water and should be at least half the daily intake of fluid. Milk is also good but may thicken phlegm or cause constipation. Fruit and vegetable juices are nutritious and useful for providing variety in daily liquids. Likewise, soups can be nutritious but may be too salty. Fluids that are not useful for preventing dehydration are soft drinks, coffee, tea, and alcohol. Although consuming reasonable amounts of these is not harmful, they can cause a person to lose fluid because of the kidneys’ reaction to sugars and diuretics. Table 2 outlines a “mantra” for geriatric nurses. The geriatric nurse is responsible for preventing dehydration in elderly patients, but prevention actually may occur through training and supervising assistive personnel or teaching family members to encourage increased fluid intake. If nursing assistants and nurses work as a team to devise interventions, they may spare patients the consequences of dehydration by preventing it before it starts. Likewise, for elders who live at home, dehydration may be prevented by making family members or caregivers aware of the importance of having liquids readily available. Some strategies for preventing dehydration are shown in Table 3.
DEHYDRATION IN TERMINAL ILLNESS In some patients who are terminally ill, dehydration may be beneficial by causing a mild euphoria. However, withholding medical nutrition and hydration is a difficult issue for many nurses and physicians, perhaps because offering food and drink is emotionally linked to sustaining life and providing patient care. Although eating and drinking indeed have symbolic meanings, artificial hydration and nutrition by means of feeding tubes and intravenous feedings may not have the same meaning to patients. Legal consensus developed over the past 2 decades holds that competent patients have a right to refuse treatments, including tube-feeding. In the case of incompetent patients, surrogates may decline treatment on their behalf. These rights are supported by both court decisions and law.23 Because nurses have a professional obligation to respect a patient’s wishes, the legal aspects of withholding medical hydration are clear: if a patient desires to discontinue treatment, the nurse should act as the patient’s advocate to secure compliance by the medical team. The ethical issues are more thorny. The manner in which the decision to discontinue medical hydration is approached by the patient and family members may be, in part, a result of information conveyed by the nurse. Therefore, nurses who care for dying elderly patients should grapple with their own beliefs, ethics, and atti-
Geriatric Nursing 2000 • Volume 21 • Number 2
Table 3 Dehydration Prevention for Elders Aim for 1500 mL of oral liquids per day for each patient unless he or she has special medical conditions, such as congestive heart failure. Allow adequate time for eating or feeding at mealtimes. Meals can provide two-thirds of daily fluids if patients are encouraged to consume liquids and have time to do so. Encourage family members to participate in feeding and teach them to encourage consumption of both liquids and food. Accommodate patient preferences for particular liquids during or between meals whenever possible. On meal trays, open all containers, pour liquids into cups or provide straws, depending on individual needs. Provide water that is available all day at bedside or chairside. Pitchers and cups must be within reach and not too heavy to be easily handled by an elderly individual alone. Offer fluids regularly during the day. Patients who don’t think to serve themselves may consume liquids when they are offered as part of a snack of other regular routine.1 Encourage consumption of fluids with medications. One study showed that liquids consumed with medications made the difference between adequate and inadequate daily fluid intake for some patients.2 Pay particular attention to patients who are not mobile or are restrained. One researcher reported observing a woman in a wheelchair who called repeatedly for something to drink and attempted to reach the water on her bedside stand. Although she was in a vest restraint, the resident slipped to the floor. The nurse put her back in her chair and tightened her restraint but did not give her a drink of water.3 1. Kositzke JA. A question of balance: dehydration in the elderly. J Geron Nurs 1990;16:4-11. 2. Chidester JC, Spangler AA. Fluid intake in the institutionalized elderly. J Am Diet Assoc 1997;97:23-30. 3. Kayser-Jones J. Influence of the environment on falls in nursing homes: a conceptual model. In: Katz PR, Kane RL, Mezey MD, editors. Advances in long-term care. New York: Springer; 1993 p. 177-95.
nutrition, a phenomenon that has been observed in rats.26 Nurses and family members may be afraid that the decision to withhold medical hydration and nutrition may cause the patient to feel hungry and thirsty. Although this subject is difficult to research, a recent study monitored 32 terminally ill patients and found that 20 patients (63%) never experienced hunger and an additional 11 patients (34%) felt hunger only initially. Similarly, 62% experienced no thirst or were thirsty only initially. In all patients, hunger or thirst symptoms were alleviated with small amounts of food, liquid, or ice chips.27 Another author suggests that the sensation of thirst in dying patients may be caused by dry mouth rather than thirst and can be relieved by ice chips or frequent sips of cold water.24 Nurses who care for dying patients will have to face each situation by helping patients and families weigh the benefits of discontinuing medical hydration. Death then may occur with less pain and fewer barriers, such as intravenous lines and feeding tubes, that may be uncomfortable to the patient and keep family members from close physical contact.
DEHYDRATION AND GERIATRIC NURSES Some nurses, especially those who work in nursing homes, put a lot of energy into preventing dehydration in elderly patients by developing protocols, suggesting changes in routines, educating family members, and motivating nursing assistants. Nurses who care for terminally ill patients have to work equally hard to overcome emotions and traditional ideas that food, love, and artificial nutrition and hydration are equal. In some cases, nurses will help patients and families choose dehydration for a dying patient, and the nurse will be required to advocate for the implementation of that decision. Although dehydration may be a different issue for each patient, a geriatric nurse’s professional practice requires a constant awareness of the importance of hydration status to an elderly patient’s quality of life. REFERENCES
tudes about discontinuing artificial hydration in a patient’s final days. The literature contains some evidence that withholding artificial nutrition and hydration at the end of life actually may reduce pain. Some physicians and nurses report observing patients who were not hydrated and had more comfortable deaths than those who were medically hydrated.24,25 Although research is needed to define the etiology of dehydration’s possible analgesic effects, it has been suggested that the increased production of ketones during calorie deprivation may cause a partial loss of sensation. Another possibility is that opioid peptides may be released in a state of advanced mal-
Geriatric Nursing 2000 • Volume 21 • Number 2
1. Warren JL, Bacon WE, Harris T, McBean AM, Foley DJ, Phillips C. The burden and outcomes associated with dehydration among U.S. elderly, 1991. Am J Public Health 1994;84:1265-9. 2. Lavizzo-Mourey RJ, Johnson J, Stolley P. Risk factors for dehydration among elderly nursing home residents. J Am Geriatr Soc 1988;36:213-8. 3. Phillips PA, Rolls BJ, Ledingham JG, et al. Reduced thirst after water deprivation in healthy elderly men. N Engl J Med 1984; 311:753-9. 4. Sansevero AC. Dehydration in the elderly: strategies for prevention and management. Nurse Practitioner 1997;22:41-57. 5. Weinberg AD, Pals JK, McGlinchey-Berroth R, Minaker KL. Indices of dehydration among frail nursing home patients: highly variable but stable over time. J Am Geriatr Soc 1994;42: 1070-3. 6. Miller CA. Nursing care of older adults. Glenview (IL): Scott, Foresman and Co.; 1990. 7. Lavizzo-Mourey RJ. Dehydration in the elderly: a short review. J Natl Med Assoc 1987;79:1033-8. 8. Yamamoto T, Harada H, Fukuyama J, Hayashi T, Mori I. Impaired arginine-vasopressin secretion associated with hypoangiotensinemia in hypernatremic dehydrated elderly patients. JAMA 1988;259: 1039-42.
87
CE
9. Armstrong-Esther CA, Browne KD, ArmstrongEsther DC, Sander L. The institutionalized elderly: dry to the bone! Int J Nurs Studies 1996;33:619-28. 10. Colling JC, Owen TR, McCreedy MR. Urine volumes and voiding patterns among incontinent nursing home residents. Residents at highest risk for dehydration are often the most difficult to track. Geriatr Nurs 1994;15:188-92. 11. Chidester JC, Spangler AA. Fluid intake in the institutionalized elderly. J Am Diet Assoc 1997;97:23-30. 12. Reedy DF. How can you prevent dehydration? Geriatr Nurs 1988;9:224-6. 13. Kositzke JA. A question of balance: dehydration in the elderly. J Geron Nurs 1990;16:4-11. 14. Hoffman NB. Dehydration in the elderly: insidious and manageable. Geriatrics 1991;46:35-8. 15. Gross CR, Lindquist RD, Woolley AC, Granieri R, Allard K, Webster B. Clinical indicators of dehydration severity in elderly patients. J Emerg Med 1992;10:267-74. 16.Weinberg AD, Minaker KL, Council on Scientific Affairs AMA. Dehydration, evaluation and
management in older adults. JAMA 1995;274: 1552-6. 17. Kayser-Jones J, Schell E. The effect of staffing on the quality of care at mealtime. Nurs Outlook 1997;45:64-72. 18. Eaton D, Bannister P, Mulley GP, Connolly MJ. Axillary sweating in clinical assessment of dehydration in ill elderly patients. Br Med J 1994;308:1271. 19. Wandel JC. The use of postural vital signs in the assessment of fluid volume status. J Prof Nursing 1990;6:46-54. 20. Himmelstein DU, Jones AA, Woolhandler S. Hypernatremic dehydration in nursing home patients: an indicator of neglect. J Am Geriatr Soc 1983;31:466-71. 21. Kayser-Jones J, Schell ES. Staffing and the mealtime experience of nursing home residents on a special care unit.Am J Alz Dis 1997;12(2):67-71. 22. Kayser-Jones J. Influence of the environment on falls in nursing homes: a conceptual model. In: Katz PR, Kane RL, Mezey MD, editors. Advances in long-term care. New York: Springer; 1993 p. 177-95.
23. Meisel A. Barriers to forgoing nutrition and hydration in nursing homes. Am J Law Med 1995;21:335-82. 24. Printz LA. Terminal dehydration, a compassionate treatment. Arch Intern Med 1992;152:697700. 25. Taylor M. Benefits of dehydration in terminally ill patients. Geriatr Nurs 1995;16:271-2. 26. Printz LA. Is withholding hydration a valid comfort measure in the terminally ill? Geriatrics 1988;43:84-8. 27. McCann RM, Hall WJ, Groth-Juncker A. Comfort care for terminally ill patients. The appropriate use of nutrition and hydration. JAMA 1994;272: 1263-6.
JILL A. BENNETT, PhD, RN, is an assistant professor in the School of Nursing at San Diego State University. Copyright © 2000 by Mosby, Inc. 0197-4572/2000/$8.00 + 0
34/1/107135
Test I.D. No.: G107135 Contact hours: 1.0 Processing fee: $9 Passing score: 70% (seven correct answers)
1. Without adequate hydration, the following medical consequences were listed EXCEPT: A. Delirium B. Pulmonary hypertension C. Cardiovascular symptoms D. Urinary tract infection
5. Which of the following is not recommended to prevent dehydration? A. Fruit and fruit juices B. Coffee C. Soup D. Water
9. Which of the following would be the best to combat dehydration in the elderly? A. Juices B. Soda C. Caffeine D. Liquid diet supplements
2. Factors that may influence the elderly to be more dehydrated include the following EXCEPT: A. Failure to concentrate urine B. Decreased thirst C. Use of other medications D. Lack of supervision and encouragement
6. What are the alleged analgesic effects of dehydration? A. Increased production of ketones that decrease sensation B. Release of opioids C. A and B D. Neither A nor B
10. Besides offering fluids regularly, what else can be done to keep an elderly client hydrated? A. Increase bowel and bladder training B. Encourage fluid intake with medications C. Offer only room temperature fluids D. Refrain from offering fluids after 8 PM to limit nocturnal incontinence
3. What is the most common standard for daily fluid intake? A. 2 to 2.5 L/day B. 1.5 to 2.0 L/day C. 1.5 L/day D. 500 mL/day
7. Orthostatic hypotension as an indicator of dehydration may be complicated by: A. Patients’ debilitated condition B. Medications or chronic illness C. Prolonged bed rest D. All of the above
4. What is the best indicator of dehydration? A. Serum osmolality greater than 300 B. Orthostatic hypotension C. Skin turgor D. Oral symptoms
8. Which of the following is another good indicator of dehydration? A. Serum osmolality less than 300 B. BUN greater than 20 C. BUN:creatinine 10:1 D. Serum sodium greater than 145
88
Geriatric Nursing 2000 • Volume 21 • Number 2
CE ANSWER/ENROLLMENT FORM To receive continuing education credit for any test in this issue, simply do the following: 1. Read the article. 2. Take the test for the article and record your answers on the form below. (You may make copies of the answer form.) You should complete one answer form for EACH test. 3. Mail the completed answer/enrollment form along with a check or money order. Payment must be included for your examination to be processed. 4. The deadline for submitting your answer/enrollment form is 2 years from the date of this issue. 5. Your results will be sent within 4 weeks after your answer form is received. Enrollees who have a passing score will receive a certificate. Instructions: Mark your answers clearly by placing an “x” in the box next to the correct answer. This is a standard form; use only the number of spaces required for the test you are taking. Test I.D. No. 1. ❑ A ❑B ❑C ❑D
2. ❑ A ❑B ❑C ❑D
3. ❑ A ❑B ❑C ❑D
4. ❑ A ❑B ❑C ❑D
5. ❑ A ❑B ❑C ❑D
6. ❑ A ❑B ❑C ❑D
7. ❑ A ❑B ❑C ❑D
11. ❑ A ❑B ❑C ❑D
12. ❑ A ❑B ❑C ❑D
13. ❑ A ❑B ❑C ❑D
14. ❑ A ❑B ❑C ❑D
15. ❑ A ❑B ❑C ❑D
16. ❑ A ❑B ❑C ❑D
17. ❑ A ❑B ❑C ❑D
Name
8. ❑ A ❑B ❑C ❑D
9. ❑ A 10. ❑ A ❑B ❑B ❑C ❑C ❑D ❑D
18. ❑ A 19. ❑ A 20. ❑ A ❑B ❑B ❑B ❑C ❑C ❑C ❑D ❑D ❑D
Credentials
Address
City
State
ZIP
Soc. Sec. No.
Phone
License: State/No. Mail to: Buchanan & Associates 1666 Garnet Ave., Suite 102 San Diego, CA 92109 For more information call: (800) 929-1233 Buchanan and Associates is an approved provider of continuing education in nursing by the American Nurses Credentialing Center Commission on Accreditation.
PROGRAM EVALUATION Strongly agree The objectives of the program were met. 1— The content was appropriate. 1— My expectations have been met. 1— This form of CE is worthwhile. 1— The level of difficulty of this test was: 1— Easy
2— 2— 2— 2— 2—
How long did this program take to complete?
3— 3— 3— 3— 3—
Strongly Disagree 4— 5— 4— 5— 4— 5— 4— 5— 4— 5— Difficult hours
❑ I have enclosed an additional $10 for rush processing. ❑ I have enclosed an additional $15 for foreign delivery.
Geriatric Nursing 2000 • Volume 21 • Number 2
83