Geriatric Nursing and Managing Oral Hydration

Afza.Malik GDA

 Managing Oral Hydration in Old Age 

Geriatric Nursing and Managing Oral Hydration
Assessment or identification of dehydration.Population in old age at dehydration risk.Acute and risk and going fluid management.Evaluation of outcomes.

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 At Risk 

    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)

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