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Combating Dehydration
In Long-Term Care

DMA Annual Meeting Preview

 Feature Article

combating
dehydrat
D
by | Lisa Stewart, CDM, CFPP
Helga Longino, RN
Diane Burton, RN
Angie Corder, RD

and UTIs in
Long-Term
Care
30 DIETARY MANAGER
Dehydration and urinary tract infections are all-too-
common problems in long-term care. This article defines
signs and symptoms of dehydration, and discusses a
study at one facility that tried a supplement to keep
residents hydrated and reduce UTIs.

tion
D
Dehydration is a form of malnutrition
water. Dehydration is defined as—and often signaled by—a sudden loss of 3 percent or more of body
weight. (Weinberg et al.)
Warren and colleagues define dehydration as “an imbal-
ance between intake and loss of fluid and the accompany-
ing sodium status.” They note that we tend to focus on
fluid volume depletion because sodium status is not always
measured.
Dehydration may take one of several forms (Huffman):
s Isotonic: balanced depletion of water and sodium,
often seen with refusal of oral intake or as a result of
diarrhea or vomiting
s Hypertonic: water losses are greater than sodium
losses, often seen with fever
s Hypotonic: proportionately greater sodium loss than
water loss, as may occur with overuse of diuretics
In long-term care, the facts are alarming:
s $EHYDRATIONISONEOFTHEMOSTFREQUENTDIAGNOSESFOR
Medicare hospitalizations. (Warren et al.)
involving life’s most fundamental nutrient:
s #OSTSOFDEHYDRATIONINWEREESTIMATEDAT
billion per year. (Mentes)
Burger and colleagues call the constellation of malnutri-
tion, dehydration, and weight loss in nursing homes “one of
the largest silent epidemics in this country.” (Burger et al.)
They describe hospitalization as “a stressful event for frail
elders.” Lack of simple nutrients can have a profound ef-
fect on quality of life as well, noted Burger and colleagues:
“Nursing home residents who do not receive adequate nu-
trition and hydration during the last months or years of
their lives are denied one of life’s greatest pleasures—the
enjoyment of food and drink of their choice in a pleasant
social environment.” (Burger et al.)
Defining the Risk
What puts our aging population at risk for dehydration? A
number of factors come into play:
s ! DECREASE IN TOTAL BODY WATER DUE TO DECLINING LEAN
s !MONGTHOSEEXPERIENCINGDEHYDRATIONPERCENTWILL
body mass
die within 30 days. (Warren et al.)
s !DECLINEINTHETHIRSTMECHANISMAFFECTINGNEARLYTWO

s /LDESTRESIDENTSAREATGREATESTRISK4HOSEOVERARE
thirds of nursing home residents, per research by Gasper)
six times more likely to be hospitalized for dehydration
than those aged 65 to 69. (Warren et al.) (Continued on page 32)

!PRILs 31
 Feature Article (Continued)

s #OGNITIVE IMPAIRMENT MAKING A PERSON LESS LIKELY TO Among the elderly, however, risk may be compounded by
drink fluids the fact that dehydration is not always easy to detect. Ac-
s .EUROLOGICALIMPAIRMENTSEGFOLLOWINGSTROKE cording to Huffman, “Classic signs of dehydration may be
s $ECLINEINRENALFUNCTIONANDTHEABILITYOFTHEKIDNEYS absent or at least obscure.” She suggests orthostatic blood
to concentrate urine pressure or pulse measurement as better indicators.
s (EIGHTENEDSUSCEPTIBILITYTOHYDRATIONSTRESSESSUCHAS A Hydration Trial
heat, fever, vomiting, or diarrhea (Garcia)
At Fountain Inn Nursing Home (Fountain Inn, SC), dehydra-
s !TTEMPTS TO LIMIT EPISODES OF INCONTINENCE BY CURTAIL- tion is a sentinel event in our quality assurance program,
ing fluid intake (prevalent among 39 percent of nursing and has been a target for quality improvement. Our care
home residents, per research by Gasper) team decided to augment industry “best practices” with a
s &EAROFPAINDUETOURINARYTRACTINFECTION54) regimen built around an oral hydration formula.
s $YSPHAGIA Given the hydration risk factors outlined above, we believe
s -EDICATIONSTHATREDUCEHYDRATIONEGDIURETICS
A common standard for fluid intake is 30 ml/kg of body
weight, with a minimum of 1500 ml per day. Another stan-
dard (Gasper) uses 100 ml/kg for the first 10 kg; then 50
ml/kg for the next 10 kg; then 15 ml/kg for the remainder.
A study of 40 nursing home residents by Kayser-Jones and
colleagues identified an average actual intake of 847 ml/
day. With dehydration comes the heightened risks of UTI,
pneumonia, decubiti, disorientation, and electrolyte imbal-
ance. (Chidester and Spangler)
Recommended strategies and solutions to dehydration in-
clude assistance with meals and beverages, adequate staff-
ing and staff training, beverages between meals, and hy-
dration carts. (Garcia)
Signs and Symptoms of Dehydration
Clinical indicators of dehydration include the following:
s 0OORSKINTURGOR
s $RYMUCOUSMEMBRANES
s #ONCENTRATEDURINEDARKCOLOR
s /LIGURIA
s 3UNKENEYES
s 2APIDHEARTBEAT
We found that popular
caffeinated beverages, such
as coffee or tea, are often
counter-productive to hydration
objectives because they cause
additional fluid loss.
32 DIETARY MANAGER
it’s not enough to just hand a resident a glass of water and
hope that succeeds. In addition, we find that popular caf-
feinated beverages, such as coffee or tea, are often coun-
ter-productive to hydration objectives because they cause
additional fluid loss. Furthermore, for individuals with
diabetes, we want to avoid beverages with simple sugar,
which could cause hyperglycemia, polyuria, and electro-
lyte imbalance. A third consideration is the osmolality of
fluid supplements offered. In some individuals, a high-os-
molar drink may trigger diarrhea, compounding—rather
than improving—the problem of dehydration.
Most importantly, supplemental electrolytes are easily
overlooked in nursing home hydration programs. Given the
importance of maintaining adequate sodium intake along
with fluid, we were interested in determining whether a
supplement of electrolytes as well as fluid could help pre-
vent dehydration.
In April 2008, we began a trial of a lemon-flavored pow-
dered drink mix supplement formulated for the fluid and
electrolyte needs of seniors*. We selected 10 residents
based on the following criteria:
s AHISTORYOFCHRONIC54)ANDOR
*GeriAide: 40 mg sodium, 20 mg potassium, 0 mg phosphorous per 4
oz serving; provided by Medtrition, Inc.
s AHISTORYOFDEHYDRATIONASTAGGEDFROMRECENTHOSPITAL- trial. Shortly after ending the trial, UTI rates rose to 6.8
ization. percent in October 2008. Based on preliminary clinical
findings, our early evidence suggests that hydration bene-
Our resident mix for the trial included individuals with dia-
fits achieved through supplementation have also improved
betes mellitus, as well as a diet order of thickened liquids.
infection control and incidence of UTI. Likewise, Mentes
Residents were 70 to 90 years of age. Residents received
concludes that adequate hydration can help prevent UTIs.
four 4-ounce supplements of mixed formula as a beverage
accompanying breakfast and lunch meals (480 ml per day). UTI Facts and Figures
A thickener was added for the thickened liquid diet.
The National Institute of Diabetes & Digestive & Kidney Dis-
Reduction in UTIs eases provides background facts and figures about UTIs:
At the outset of our trial, we measured the following data: s !PPROXIMATELY ONE
THIRD OF HOSPITALIZATIONS WITH INFEC-
tion can be attributed to UTIs (or 1/3 of 2 million).
s -ONTHLY54)RATEPERCENT
s 2ISKFACTORSINCLUDEADVANCINGAGEFEMALEGENDERDIABE-
s 0RESENCEOF-23!INURINEPERCENT
tes, and cauterization.
In August 2008, after five months on the trial, we ob-
QUARTER
served:
s -ONTHLY54)RATEPERCENT
s 0RESENCEOF-23!INURINEPERCENT
We also found that although presence of Clostridium dif-
ficile has been common in nursing home residents, we had
no incidence of this among treated residents during the
s 7ITHINTHEAGERANGE54)SACCOUNTFORONE
of all infections, and bacteriuria is typically seen in half
of women and one-third of men.
s !LSOCOMMONAMONGOLDERINDIVIDUALSISINFECTIONWITH
a broad range of pathogens. Antibiotic-resistant infection
is more common in the nursing home environment.
(Continued on page 34)

a l one Preventing dehydration requires attention

r to electrolytes, too. GeriAide is specially
w ate h. mp
lete formulated for the fluid and electrolyte
en u g c o
Wh ot enoh water fo
ra needs of your clients at risk for dehydration.
Low osmolality and electrolyte balancing
is n t mix wni .
t topped off with a light lemon flavor make
us io GeriAide the perfect hydration solution for
i d e: J solut
r i A i o n your residents.
Ge ydrat
deh Call for more information

PO Box 5387 • Lancaster, PA 17606

Toll free: 1-800-509-2687
• Prevent unnecessary hospitalizations
• Save suffering and costs associated with dehydration & UTIs
• Deliver comfort and quality of life to your residents

!PRILs 33
 Feature Article (Continued)

Costs of Dehydration and UTIs

The nation’s healthcare costs could be
The annual cost of UTIs in the US is $1 billion (Nation- reduced dramatically through proactive
al Institute of Diabetes & Digestive & Kidney Diseases).
Grabowski and colleagues examined hospital admissions management of dehydration and other
for nursing home residents in the state of New York and factors in nursing homes.
concluded that the nation’s healthcare costs could be re-
duced dramatically through proactive management of de-
hydration and other factors in nursing homes. Specifically,
they noted that:
s (EALTHCARECOSTSFORNURSINGHOMERESIDENTSADMITTEDTO
hospitals in New York (2004) were $972 million.
s 0REVENTABLEHOSPITALIZATIONSFORAlVE YEARPERIODIN
New York costs $1.24 billion.
s $EHYDRATIONISONEOFTHEMAJORhPREVENTABLECONDI-
tions” leading to hospitalization, with a cost of $89.1
million for New York alone during the study period.
s 54)ISANOTHERMAJORhPREVENTABLECONDITIONvACCOUNT-
ing for healthcare costs of $200.9 million for New York
alone during the study period.
s (OSPITALIZATIONFROMPREVENTABLECONDITIONSSUCHAS
dehydration is increasing.

A Proactive Approach
We need to recognize that many nursing home residents
are at risk for dehydration, and that simply offering bev-
erages is not enough to prevent any unnecessary illness,
achieve quality assurance objectives, contain healthcare
costs, and ensure the highest possible quality of life for
each individual. Our findings at Fountain Inn suggest that
it is effective to provide a fluid and electrolyte supplement
in tandem, directly with meals to improve resident well-
ness. Hydration management cannot be a passive endeav-
or, and it requires a concerted, consistent effort from all
healthcare team members. DM

Lisa Stewart, CDM, CFPP is a Certified Dietary Manager at Fountain Inn Nursing Home in Fountain Inn, SC; Helga Longino, RN, is Director of Nursing; Diane
Burton, RN, is Assistant Director of Nursing and Infection Control Specialist; and Angie Corder, RD, is a Consultant Dietitian at Fountain Inn.

References

Burger, Sarah Greene, J. Kayser-Jones, and J. Prince Bell. Malnutrition and dehydration in nursing homes: key issues in prevention and treatment. National Citizens’
Coalition for Nursing Home Reform 2000.
Chidester, JC and AA Spangler. Fluid intake in the institutionalized elderly. J Amer Dietetic Assn 97 (1997): 23
Gasper, PM. Water intake of nursing home residents. J Gerontol Nurs 1999 25 (4), 23-9.
Grabowski DC, O’Malley J, Barhydt, N. The Costs and Potential Savings Associated With Nursing Home Hospitalizations. Health Affairs. 2007; 26 (6): 1753-1761.
Huffman, GB. Evaluation and management of dehydration in the elderly. American Family Physician, April 1996.
Kayser-Jones et al. Factors contributing to dehydration in nursing homes. J Am Geriatrics Society 1999. 47 (10): 1187.
Mentes, JC. Hydration management. Nursing standard of practice protocol. Evidence-based content. Hartford Institute for Geriatric Nursing, 2008.
National Institute of Diabetes & Digestive & Kidney Diseases. Overcoming bladder disease, 2002.
Warren, JL et al. The burden and outcomes associated with dehydration among US elderly. American Journal of Public Health, 84 (8), 1994.
Weinberg, AD and KL Minaker. Council on Scientific Affairs, American Medical Assn. Dehydration: evaluation and management in older adults. JAMA 1995. 274:19:
1552.

34 DIETARY MANAGER