Christine Kilgore is a freelance writer in Virginia.
A shift in thinking is taking place among geriatric-medicine and long-term care experts about how to define and manage dehydration in nursing homes.
Dehydration has long been designated by payers and regulators as an indicator of quality of care in the long-term care setting, but a growing cadre of long-term care experts is urging that it be regarded more as a medical condition or syndrome that is frequently associated with common disease processes, medications, and the natural physiologic changes of aging. Such a shift not only makes dehydration an unreliable quality measure, they say, but also changes how caregivers should view prevention and management.
“I've been a director of nursing in geriatrics for 19 years and, until recently, I used to think of dehydration only from the angle of hydrating people and not from the angle of understanding the physiologic changes under way and all the medical issues,” said Cathleen Bergeron, RN, director of nursing at the 260-bed Soldiers' Home in Holyoke, Mass. “I think we're becoming much more astute in how we view the problem and care for patients.”
Increasingly, researchers also acknowledge that the condition's physical signs and symptoms aren't reliable as core elements of diagnosis. AMDA's recently revised clinical practice guideline on dehydration and fluid maintenance in the long-term care setting emphasizes that signs and symptoms can be deceptive and vague and that ultimately, diagnosis is a biochemical one.
Thorough laboratory evaluation—assessment that goes beyond use of the blood urea nitrogen (BUN)-to-creatinine ratio as a sole criterion for diagnosis—is the “clinical gold standard” for evaluating and monitoring dehydration, the document says.
On the prevention front, relatively few studies have been published, and trials of interventions to improve fluid intake in nursing homes and other long-term care settings have been inconclusive or contradictory. The best approaches to prevention, the sources for this article said, appear to be those that combine efforts to identify acute illness early, evaluate and identify individual risk factors, and increase fluid intake by individuals and resident populations.
Certainly, the consequences of dehydration are serious. In addition to predisposing frail residents to complications such as infections, acute confusion, falls, and functional decline, the condition has been shown to double hospital mortality in patients admitted with stroke, to double the risk of pressure ulcers, and to increase the length of hospital stay in patients with community-acquired pneumonia.
“Dehydration is something that caregivers should always be thinking about,” said Ms. Bergeron. “It should be right up there, right at the top of the list.”
Understanding the Problem
As David Thomas, MD, CMD, and other members of a body known as the Dehydration Council see it, one main problem with dehydration is that it has been loosely defined in clinical settings and too often has been based on superficial assessments or the misinterpretation of test results.
Indeed, not only has the sense of the word not been limited to the classical notion of depletion of water, but also there is no universally accepted definition of dehydration, which is why reliable estimates of prevalence are hard to come by. The Dehydration Council formed several years ago and has received various grants to review the literature and develop consensus and a position paper on dehydration in long-term care.
It is clear, however, that a shift in thinking is necessary, said Dr. Thomas. “Physicians have been taught to rely on physical signs for the presence of dehydration, but we've had some really nice studies done in [emergency departments] and LTC settings that show that most of these signs [from skin turgor to dry mucous membranes] are nonspecific and don't work for drawing diagnostic conclusions,” said Dr. Thomas, professor of medicine at St. Louis University.
“And overall,” he said, “we've gotten ourselves into this conundrum of calling everything dehydration, which doesn't do anyone any good because it no longer guides therapy.”
In a review of dehydration published in the Journal of the American Medical Directors Association in 2008 (J. Am. Med. Dir. Assoc. 2008;9:292-301), Dr. Thomas and other members of the Dehydration Council suggested that the clinical definition for dehydration—the loss of total body water (with or without salt)—is the most practical definition and addresses the problem most effectively.
Within this rubric, physicians should then differentiate dehydration into either a loss of water (hyperosmolar) or a loss of water and sodium (hyponatremia) and treat it accordingly. The AMDA guideline contains algorithms for this distinction as well as for the assessment and treatment of hyponatremia, which may be associated with isotonic, hypotonic, and hypertonic osmolarity and is “where evaluation gets complicated” and differential diagnoses are involved, said Dr. Thomas, who also chaired AMDA's dehydration guideline panel.
Laboratory assessment is critical for diagnosis, according to both the JAMDA-published review and the AMDA guideline. At minimum, the work-up should include values for blood urea nitrogen, serum bicarbonate, creatinine, glucose, sodium, calcium, and potassium. In addition, serum osmolarity should be either calculated or directly measured, the documents say.
Just as dehydration cannot be defined by a single symptom or sign, the problem cannot be defined by any single laboratory value—including the BUN-to-creatinine ratio. “Many research papers use this ratio to calculate rates of dehydration, but it's not physiologically accurate,” Dr. Thomas said. “The BUN:Cr ratio works well as long as you have normal renal function, but 60%-80% of older people in nursing homes don't have normal renal function.”
Diagnosis should be made with a broader set of lab measurements on hand, he said, in addition to the staff's clinical assessment of physical signs and knowledge of the patient's history.
While there has historically been reasonable consensus on risk factors for dehydration—from acute and chronic illnesses to dysphagia, dementia, and various medications—appreciation is growing for the many physiologic changes of aging that raise risk levels, several experts told Caring for the Ages. Total body water naturally declines—as do kidney function, osmoreceptor sensitivity, thirst, and the ability to quickly correct fluid and electrolyte imbalances.
Dehydration near the end of life, the AMDA guideline notes, can offer benefits for some individuals, such as the ease in respiration and lessened cough and congestion that can come from decreased levels of body fluids and pulmonary secretions.
“The myth of dehydration is that it is intrinsically preventable or a sign of neglect,” wrote Dr. Charles Crecelius, MD, PhD, CMD, of the Washington University in St. Louis, in an editorial published in JAMDA in 2008 (J. Am. Med. Dir. Assoc. 2008;9:287-8).
“It is time to realize,” he wrote, “that [dehydration] is better described as a geriatric syndrome frequently associated with common diseases and declining stages of the frail elderly.”
Notable is the fact that federal regulations don't recognize any dehydration as unavoidable.
Prevention and Management
Prevention may be an increasingly complex and even contentious term when it comes to the problem of dehydration in long-term care, but it's still one with relevance and urgency among the experts.
The need for a daily emphasis on hydration, earlier identification of fluid imbalances and acute illness, increased awareness of risk factors, more effective communication of clinical changes—and increasingly, preventive interventions that are individualized and targeted to specific risk factors and risk levels—are among the strategies and goals of nursing homes and other facilities across the country, sources say.
Janet C. Mentes, PhD, of the University of California, Los Angeles, School of Nursing, who has studied dehydration and hydration status in nursing homes, said residents can benefit from varying approaches to hydration, depending on their characteristics and risk factors.
A resident who is a “sipper”—who never takes more than a few sips at a time, even of his or her preferred beverage—may benefit most from being offered frequent small amounts of fluid throughout the day, for instance. A resident with dementia, on the other hand—one who is able to drink but just forgets—may benefit most from social cues and from being in social situations and activities where beverages are served.
In a 6-month observational study of 35 frail residents in two nursing homes in California, in which Dr. Mentes produced a “typology” of hydration problems, she found that the residents who fell into the “won't drink” category were especially vulnerable to dehydration events. This group included the “sippers” as well as residents who restricted their intakes of fluid because they feared incontinence (J. Gerontol. Nurs. 2006;32:13-9).
The fear of incontinence, said geriatric nurse practitioner Christina Traber, RN, has been increasingly appreciated as a risk factor for dehydration in recent years. “For these residents, it's often an educational issue—letting them know that becoming dehydrated is really not a good option for controlling their incontinence,” said Ms. Traber of the Charlevoix Health Care Center in St. Charles, Mo.
At the Soldiers' Home, dehydration is a regular topic for members of the facility's “bowel and bladder team,” Ms. Bergeron said. The prevention of dehydration is part and parcel of keeping residents clean and dry and choosing the best incontinence products, she said.
The approach to preventing dehydration in Ms. Bergeron's nursing home includes broader hydration efforts as well. Sports bottles have replaced water pitchers as drinking tools because they are easier for residents to use, and volunteers bring around “nutrition carts.” A canteen is open 12 hours a day, residents have easy access to vending machines, family members are encouraged to bring in food and beverages, and fluid and food input is monitored when concerns arise, said Ms. Bergeron, who served on AMDA's dehydration-guideline panel.
Dr. Thomas said that while research on hydration interventions has yielded disappointing results overall, it has suggested that increasing beverage choices can increase the amount of fluid that residents will consume. Still, basic efforts to improve access to fresh water continue to be important, he said.
“Have focus groups and ask the aides, for instance, ‘What are barriers to getting water and ice? What makes it harder for you to routinely fill pitchers?’” he advised. “Sometimes there are identifiable institutional barriers.”
The goal of managing dehydration, said Eric G. Tangalos, MD, CMD, of the Mayo Clinic, Rochester, Minn., and a member of AMDA's dehydration-guideline panel, should be “to intervene sooner rather than later.”
Caregivers must also remember, he said, that “people who get into trouble with salt and water balance are likely to have recurrent troubles with salt and water balance, so once the problem has been identified, you need to stay with it.”
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