Jeannette Y. WickAbnormal depletion of body fluids is a major threat to elderly nursing facility residents—and a major focus of increased survey scrutiny. Here we’ll look at this multifaceted problem: who’s at greatest risk, how medication and feeding issues factor into the dehydration equation, and what pharmacists can do to help. Imagine being on the beach for the day, playing in the waves or hitting a volleyball back and forth with friends. All you can think about is a glass of water or a popsicle. You walk to your blanket, grab your wallet, and head off to quench that thirst. Now imagine being restrained in a chair, or confined to bed in a warm room, and suddenly deciding you’re thirsty. Maybe you can’t quite verbalize your need for water or juice, or perhaps you aren’t quite sure what you need. Maybe the pitcher is just a little too far away to reach, or too heavy to grip. Or maybe you’re afraid to drink any more water because that will necessitate another assisted trip to the toilet. These are the sorts of predicaments many of the elderly patients we serve face daily. All too frequently, dehydration is the result.
Compelling Motivators of ChangeAdministrators of long-term care facilities are beginning to consider detection of dehydration a key risk management issue.1 They’ve been nudged in this direction by the Health Care Financing Administration’s (HCFA) increasingly tighter survey criteria. Since enactment of the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87), HCFA’s standards have become more and more prescriptive concerning how care is provided.2 Beginning in 1990, HCFA implemented regulations focusing on reduction of restraint use, discontinuation of unnecessary psychotropic medications, and prevention of hospitalization. In 1995, the agency again stepped up scrutiny of nursing facility quality with revised survey, certification, and enforcement criteria.2,3Clearly, stricter federal regulations have greatly improved many aspects of nursing facility care. For example, use of physical restraints has decreased by approximately 50%, and experts estimate that antipsychotic medications are used 25%–35% less frequently than in 1990.2 Encouraged and motivated by those successes, HCFA recently revised its inspection process to place more emphasis on prevention of pressure ulcers, abuse of residents, and malnutrition and dehydration.3 Now federal health officials are looking to various health care professional organizations to join in a national campaign focusing on prevention of malnutrition and dehydration.4 Aside from HCFA regulations, long-term care administrators have another reason to be concerned about dehydration: increased litigation. In 1998, neglect verdicts against long-term care facilities increased to 27, up from 16 cases in 1997. Many of those cases were related to dehydration, and the average compensatory award was $1.3 million—a fourfold increase over average awards in 1995. These figures do not include out-of-court settlements.5 Considered separately, increased oversight and increased risk of litigation are serious concerns; together, they provide a strong impetus to address dehydration immediately.
A Serious Threat to SeniorsElderly people are at greatest risk for dehydration and its potentially life-threatening consequences. Elders aged 85–99 are six times more likely to be hospitalized for dehydration than those aged 65–69. More than 18% of those hospitalized for dehydration will die within 30 days, and associated mortality increases with age. Men appear to dehydrate more often than women.6 The incidence of dehydration is probably underestimated quite seriously, because dehydration is often masked by other conditions.1In an effort to prevent dehydration and its serious complications, HCFA has issued care planning guidelines that aim to foster better detection through use of identified risk factors.7 Exhibit 1 lists triggers promulgated by OBRA legislation. These triggers indicate the need for more intense assessment of certain residents.8 HCFA surveys will now look for those residents at risk for dehydration, especially those who have lost weight, have been tube-fed, or have had prior episodes of dehydration.4
The Dynamics of DehydrationWater accounts for one-half to four-fifths of the average healthy adult’s body weight.9 This translates to approximately 72% of body mass in younger adults. As we pass 60 years of age, total body mass attributed to water declines to less than 60%.8 For most adults, about 1500 ml of water daily maintains adequate hydration.8 Normally adults begin to experience thirst sensations when they’ve lost 0.8%–2% of their body weight; rehydration should begin long before thirst kicks in. Once fluid loss from any source exceeds 2%–3%, clinical signs and symptoms occur, and simple fluid replacement may not be sufficient.9Older adults, even those who are healthy, are at higher risk for dehydration for two reasons: reduced fluid intake, and increased fluid loss. Altered thirst, changed functional status (even within normal limits), and greater use of medication are generally the cause.1 Disease processes and changes that surpass those normally expected can also impair thirst response.1–3 With age, the µ-opioid drinking drive declines.8 Loss of circadian rhythm leads to altered arginine vasopressin, resulting in frequent nocturia and increased fluid loss.10 Vasopressin responses to hypo- volemic stimuli decline.11 Residents with Alzheimer’s disease may experience even greater thirst mechanism impairment than others, and residents who have swallowing difficulties may require thicker liquids.9 Residents requiring assistance with activities of daily living (ADLs) may have limited fluid intake, and they need aggressive interventions to maintain hydration.4 Avoiding dehydration requires constant attention from the care team, and HCFA advocates including problems of dehydration and related conditions in the care plan. While there are various ways to estimate residents’ fluid needs, experts generally agree that most elderly residents need 1500–2500 ml of fluid daily.1,9 Figure 2 lists questions HCFA surveyors often pose to health care professionals and facility administrators to ascertain whether procedures for assessment and management of weight loss and/or dehydration are adequate.4
Assessment of DehydrationEven among healthy individuals, the sensation of thirst often occurs only after dehydration has started, so thirst is not a good indicator of dehydration. Dehydration can be chronic, resulting from continuous inadequate fluid intake; or acute, resulting from abrupt fluid loss without replacement.9 Signs and symptoms of dehydration may be vague and can easily be confused with those of other medical conditions. Further, there are three types of dehydration, each requiring a slightly altered management approach (see Figure 3).1
There is no universally accepted method of testing for dehydration, and each resident’s presentation and circumstances will dictate how to proceed.1,8,9 When assessing long-term care facility residents for dehydration, clinical dieticians are trained to consider dependency characteristics, communication skills, cognitive abilities, mealtime feeding skills and appetite, frequency of medications, and fluid intake from food and beverages.8 Crude evaluation methods include evaluating urine color (as dehydration progresses, urine color darkens) and weight (one pound of body weight is equivalent to 470 ml of water).9 Lab work can help, although most references stress that changes from baseline values are more telling than abnormal values, as abnormal values are "normal" for some individuals.1,11 Electrolytes, osmolality, creatinine, serum urea nitrogen, hematocrit, and hemoglobin can help establish a diagnosis.1,7
Management StrategiesA team approach is best, since each discipline will have a unique perspective on dehydration. Understanding that residents of long-term care facilities are at increased risk for dehydration, especially because many of them must be fed by limited numbers of staff,1 each team member must be constantly vigilant. Residents are older and sicker, placing them at increased risk, and funds for treatment are often limited.12 Residents who rely on enteral feeding as a source of nutrition need supplemental free water in their diets.1,10Early signs and symptoms of dehydration include headache, fatigue, skin flushing, heat intolerance, dizziness, dry mouth or eyes, and dark urine. Since these symptoms are fairly nonspecific, they can be misleading. Advanced dehydration is characterized by difficulty swallowing, clumsiness, shriveled skin, sunken eyes, visual disturbances, painful urination, numb skin, muscle spasm, and delirium.9 Long-term care facility employees can expect HCFA surveyors to ask questions about the signs and symptoms of dehydration, as well as water availability.4 The consequences of dehydration are many. Figure 4 lists conditions that can be caused or aggravated by dehydration. Of these, three are of considerable concern for the elderly: constipation, cognitive impairment progressing to delirium, and hypotension. These conditions are common in the elderly, and increase risk for the resident and the facility. With dehydration, cognitive impairment includes impaired mathematic ability and short-term memory, and hampered visual tracking.9
The Best Defense: PreventionOnce dehydration becomes a problem, the entire health care team must be involved in its resolution, and specific dehydration management strategies must be included on the resident’s care plan. The simplest and most effective strategy is to ensure that all residents consume adequate volumes of fluid. Palatability of fluid is important in developing an appropriate fluid plan,8 as is consideration of the individual resident’s preferences.9 This last point is crucial, as HCFA continues to place greater emphasis on residents’ rights and preferences.3
Medication IssuesDuring the drug regimen review process, consultant pharmacists must be aware of the potential for dehydration to complicate treatment. Also, they must understand and note the relationship between some medications and hydration status.First and foremost, diuretic use must be scrutinized carefully and frequently; this includes not only medications designated as diuretics by class, but drugs that may cause diuresis as a side effect and foods (e.g., alcohol and caffeine) that can exacerbate the problem.9 Pharmacists must consider that some drugs, including all thiazide diuretics, chlorpropamide, carbamazepine, morphine, tricyclic antidepressants, haloperidol, and phenothiazines, can decrease free water clearance and cause hyponatremia.10 Consideration of those agents that alter thermoregulation is also important. Antipsychotics, tricyclic antidepressants, anticholinergics, selective serotonin reuptake inhibitors, lithium, beta blockers, and carbamazepine can make residents more sensitive to heat. Whenever bulk-forming laxatives are prescribed or stool softeners used, attention to increased hydration can prevent impaction or dehydration. Finally, the consultant pharmacist can observe the facility’s medication pass procedure and, if appropriate, recommend increasing the amount of fluid offered with each dose. Studies indicate that there is a positive and noteworthy correlation between the number of medications a resident receives and the volume of non-meal fluid consumed.8
What Pharmacists Can DoThe pharmacist who participates on various committees and task forces in the long-term care facility will have more opportunities to recommend action steps to combat dehydration. Pharmacists might cite the following facts and figures in their efforts to help other caregivers and facility administrators understand the magnitude of the problem and the opportunities for change:
In a move to provide health care professionals with more tools to fight dehydration, HCFA has posted best practice guidelines on the World Wide Web that consultant pharmacists can use to help client facilities develop innovative risk management strategies. The agency is also working with the American Dietetic Association, clinicians, consumers, and facilities to increase its repository of information on dehydration issues.3 The Web site also lists some hydration programs identified by HCFA as among the best in the country (see Figure 5).
In remarks last year, President Clinton said that inspections conducted by HCFA are too predictable,13 and that survey schedules must now be staggered and place greater emphasis on malnutrition and dehydration.4 The bad news is that a lack of predictability will remove part of the safety net provided by the experience of previous surveys. The good news is that HCFA has given clear signals that the agency will be looking at specific quality-of-care issues and involving staff, ombudsman, and residents more in the survey process. Focused caregiver training and inclusion of malnutrition and dehydration as topics of discussion in regular staff meetings will help prepare facilities for successful survey experiences. In addition to heightened awareness and detection, effective prevention of malnutrition and hydration requires long-term care facilities and health professionals to work together to strike the right balance of respect for resident preference and appropriate medical care.1–3
References
1. Weinberg AD, Minaker KL. Dehydration: evaluation and management in older adults. JAMA 1995; 274:911–2.
Jeannette Y. Wick, RPh, MBA, is Chief Pharmacist, District of Columbia Department of Human Services, Washington, D.C.
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