Frail elders are at high risk for underhydration or dehydration due to age-related changes that place them in a delicate state of physiologic homeostasis that can easily be disrupted with the addition of even minimal physiologic stress. Dehydration is a prevalent yet easily prevented/treated problem of the elderly (Hoffman, 1991; Kositzke, 1990); however, the importance of maintaining adequate hydration in elderly patients is often overlooked until more dramatic symptoms, such as acute confusion (AC), highlight the problem. With the onset of AC and the brain dysfunction it heralds, the elder's prognosis becomes significantly more dire. It is important to monitor the hydration status of geriatric patients carefully to prevent further decline in functional health which is a known consequence of AC Francis & Kapoor, 1992; Murray et al., 1993).
This article reviews the relationship between AC and dehydration, suggests ways to help practitioners prevent AC by eliminating precipitating factors, and discusses the need for hydration management in elders. A case example is used to illustrate the importance of hydration management in vulnerable eiders with already low physiological reserve and compromised cognition.
Acute confusion is a state of brain dysfunction that has a rapid onset, brief duration, and fluctuating course. This transient state of dysfunction is signaled by impaired orientation and memory, disorganized thinking and perception, increased distractibility, disrupted sleep-wake cycle, and hyper- and/or hypoactive behavior (Foreman, 1989; Lipowski, 1990).
Neelon and Champagne (1992) indicate that the three areas of the brain most likely affected by AC include the cortical and mid-brain structures responsible for thinking, perception, and memory; the reticular activating system responsible for attention and wakefulness; and the autonomie system responsible for psychomotor and regulatory functions. Despite the global dysfunction caused by AC, it is clearly a transient dysfunction caused by physiologic, psychologic, or environmental factors. Acute confusion has the potential for resolution and can be prevented in many cases if the appropriate précipitants (i.e., fluid imbalance) are vigilantly monitored in susceptible eiders.
Incidence rates for AC in hospitalized elders have been documented from as low as 12% to as high as 80%, with 20% to 40% being the most frequently reported range (Foreman, 1989; Rockwood, 1993). The wide variance in rates of AC is likely related to different modes of measurement, methodological issues, and type of treatment setting.
Duration of AC episodes vary and have been reported to last from t day to 60 days. Sirois (1988) documented consultation cases of delirium in hospitalized elders and reported varying degrees of duration, from less than 24 hours (20%) to up to 30 days (13%). This variability in duration rates is compounded by the fact that in about 10% of patients, AC recurs (Rockwood, 1993). Levkoff and associates (1992) suggest that there is only a partial resolution of all AC symptoms on discharge. In fact, their study reponed that only 4% of patients with AC experienced complete resolution of all new AC symptoms by discharge, and that by 6-month follow-up, a remarkably small percentage (17.7%) of patients had experienced resolution of symptoms.
Additionally, patients who suffer an AC episode while hospitalized experience poorer outcomes than patients who do not (Table 1). Negative sequelae include a longer length of stay, increased mortality during and post hospitalization, discharge to a higher level of care, and future institutionalization.
The equally dismal outcomes for dehydrated elderly patients in terms of morbidity and mortality further complicate the clinical picture (Warren et al., 1994). Thus, an important etiologic question is posed: What comes first, AC or dehydration? This article proposes that dehydration is a primary precipitating factor in the development of AC in frail elders, and forms the basis for future intervention research.
PREVENTION OF ACUTE CONFUSION
Prevention of AC is based on the premise that two conditions are necessary for AC to develop: a vulnerable patient and precipitating factors (Inouye, 1994). Practitioners can thus anticipate which elderly persons are vulnerable to AC given specific individual risk and precipitating factors, and at what point during their treatment AC may occur. Synthesis of this information can help the gerontological nurse prevent episodes of AC in frail elders. Prevention of AC is essential to avoid poor outcomes such as increased mortality and decreased cognitive and functional status (Murray, 1993).
Precipitating factors are healthrelated or health setting-related factors that interact with the vulnerabilities of the elderly individual to increase the risk of the development of AC. Precipitating factors that have been most frequently identified in the literature include infection, multiple medication usage, hypoxia, fluid/electrolyte imbalances, and liver and kidney dysfunction. Less frequently identified conditions include temperature imbalance, fracture on admission, environmental issues, and hypotension.
Mr. C., 82-year-old man with a previous diagnosis of vascular (multi-infarct) dementia and liver disease, was admitted to the Emergency Treatment Center (ETC) of a medical center for evaluation and treatment of a precipitous decline in both cognitive and functional ability (rule out stroke). He displayed increasing confusion, paranoid ideation ("who were those strangers in the house?"), and extreme weakness with gait changes. Mr. C. spent more than 8 hours in the ETC receiving a computed tomography scan, chest x-ray, blood work, electrocardiogram, as well as several neurological work-ups, multiple mental status reviews, and a rectal examination. Although during that time he was able to void only 20 cc of urine, none of the various staff assigned to his case inquired if he was hungry or thirsty, nor offered him anything to eat or drink. After more than 6 hours in the ETC, Mr. C.'s family inquired if he might have some dinner, only to be informed that no late trays were available at 7 p.m. When Mr. C. was finally admitted to his room around 10 p.m. (on a transplant unit, as no other beds were available), his family had to request a bedside pitcher of water and glass from the staff. The next morning when they arrived back in his room, the still-brimming water pitcher remained intact, but the glass was nowhere in sight.
Outcomes for Hospitalized Elders Experiencing an Acute Confusion Episode
THE VULNERABLE ELDER
Elders are at increased risk for developing AC based on individual and health-related characteristics. Characteristics that indicate vulnerability in elderly individuals are advanced age (>80 years); pre-existing cognitive impairment; and multiple illnesses - all criteria which were met by Mr. C. Less frequently cited characteristics are: male gender, vision impairments, and history of alcoholism - the first two of which characterized by Mr. C.
PREVENTIVE INTERVENTION: WHY HYDRATION MANAGEMENT?
Preventive interventions include those actions designed to prevent an episode(s) of AC based on the elderly individual's vulnerabilities and the presence of precipitating factors. In the case of Mr. C., dehydration was an identified precipitant that contributed to AC superimposed over dementia during his hospitalization. This scenario is not unusual; in fact, multiple studies have identified dehydration or laboratory data indicative of dehydration (Francis, Martin, & Kapoor, 1990; Inouye, Viscoli, Horwitz, Hurst, Oc Tinetti, 1993) as a significant precipitating factor of AC. Further, dehydration may serve as an antecedent condition for other documented précipitants of AC, such as infections and medication toxicity, as well as being a precipitant itself. In addition, dehydration is more likely to be prevented through direct clinical actions than either infections or medication toxicity. Recent attention has further highlighted the prevalence of dehydration in elderly, retired Medicare patients, with 6.7% of Medicare hospitalizations in 1991 having dehydration as one of five reported diagnoses (Warren et al., 1994). Significant numbers of these same Medicare patients also had acute infections, like pneumonia or urinary tract infections, as a concomitant diagnosis.
Indicators of Dehydration in Acutely III Elderly Patients
The term dehydration is used to signify different fluid/electrolyte problems, usually based on the concentration of sodium. Although many different types of dehydration are encountered, the most prevalent type is a suhclinical state of dehydration or chronic underhydration where the elder does not adequately replenish fluids and becomes hypernatremic (Weinberg, Minaker, & the AMA Council on Scientific Affairs, 1995).
Clinical indicators of dehydration in elderly individuals are often subtle. Gross and colleagues (1992) found that the indicators listed in Table 2 were highly correlated with physician dehydration ratings which included physical examination results and laboratory studies, and were unrelated to age. As laboratory results can be affected by many age-related changes, laboratory data of elders are most helpful when interpreted as a change from baseline values rather than as a single deviant value (Table 2). Thus, measurement of dehydration in the elderly is challenging and needs to be individually assessed.
In the elderly, AC is a complex, multidimensional phenomenon that has dire consequences if not immediately treated. Additionally, the multiple precipitating factors and individual vulnerabilities of elders further complicates intervention in AC. To date, intervention research has been inconclusive for several reasons, most commonly because the global application of interventions were not well-matched to the precipitating factors for AC.
In the case of Mr. C., a patient at high risk for both dehydration and AC, an overall hydration management plan would have clearly been beneficial. The nurses on the transplant unit where Mr. C. was admitted were caring and proficient, but unused to ministering to octogenarians, as their traditional clientele were considerably younger, received fluids via TV postoperatively, and had their output easily monitored by a catheter bag. Regrettably, this potentially dangerous situation for older adults may not be so unique. In this case example, as for many hospitals nationwide, the last few years have been characterized by "restructuring," and "downsizing" of both patient beds and nursing personnel, to the extent that staff now routinely receive all types of "overflow" patients, ranging from children with orthopedic problems to neurologically compromised older adults.
Particularly disconcerting in the case example was the fact that the hospital's full-time, clinically astute gerontological nursing specialist (who provided consultation housewide) had resigned 3 months earlier, and her position had remained unfilled (presumably as a cost-cutting measure, because qualified candidates for this role were available in-house). Had there been such a nurse consultant available, perhaps the ETC and transplant unit staff would have been better informed of the dangers of dehydration in frail elders, and taken more initiative in providing this important element of good nursing care.
Literature supports that dehydration is a common precipitating factor in the development of AC in the frail elderly. This article discussed the management of precipitating factors such as dehydration. Prevention of "geriatric conditions" like dehydration should be attempted because of the numbers of frail elders who could benefit from such care.
- Foreman, M. (1989). Confusion in the hospitalized elderly: Incidence, onset and associated factors. Research in Nursing Sf Health, 12, 21-29.
- Francis, J., & Kapoor, W. (1992). Prognosis after hospital discharge of older medical patients with delirium. Journal of the America« Geriatrics Society, 40, 601-606.
- Francis, J., Martin, D., & Kapoor, W. (1990). Prospective study of delirium in hospitalized elderly. Journal of the American Medical Association, 263, 1097-1101.
- Gross, C., Lindquist, R., Anthony, W., Granieri, R., Allard, K., & Webster, B. (1992). Clinical indicators of dehydration severity in elderly patients. The Journal of Emergency Medicine, 10, 267-274.
- Huffman, N. (1991). Dehydration in the elderly. Insidious and manageable. Geriatrics, 46(6), 35-38.
- Inouye, S. (1994). The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. The American Journal of Medicine, 97, 278-288.
- Inouye, S-, Viscoli, C., Horwitz, R., Hurst, L., & Tinetti, M. (1993). A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Annals of Internal Medicine, 119, 474-481.
- Kositzke, J. (1990). A question of balance. Dehydration in the elderly. Journal of Gerontological Nursing, 16(5), 4-11.
- Levkoff, S., Evans, D., Liptzin, B., Cleary, P., Lipsitz, L., WeUe, T., Reilly, C-, Pilgrim, P., Schor, J., & Rowe, J. (1992). Delirium. The occurrence and persistence of symptoms among elderly hospitalized patients. Archives of Internal Medicine, 152, 334-340.
- Lipowski, ZJ. (1990). Delirium: Acute confusional states. New York: Oxford University Press.
- Murray, A., Levkoff, S., Wetle, T., Beckett, L., Cleary, P., Schor, }., Lipsitz, Rowe, J-, & Evans, D. (1993). Acute delirium and functional decline in the hospitalized elderly patient- Journal of Gerontology: Medical Sciences, 48, M181-186.
- Neelon, V, & Champagne, M. (1992). Managing cognitive impairment: The current bases for practice. In S. Funk, E. Tournquist, M Champagne, & R. Wiese (Eds.) Key aspects ofeldercare: Managing falls, incontinence and cognitive impairment. New York: Springer Publishing Co.
- Rockwood, K. (1993). The occurrence and duration of symptoms in elderly patients with delirium. Journal of Gerontology: Medical Sciences, 48, M162-M166.
- Sirois, F. (1988). Delirium: 100 cases. Canadian Journal of Psychiatry, 33, 375-378.
- Warren, J-, Bacon, E-, Harris, T., McBean, A., Foley, D., & Phillips, C. (1994). The burden and outcomes associated with dehydration among U.S. elderly, 1991. American Journal of Public Health, 84, 1265-1269.
- Weinberg, A., Minaker, K., & the Council on Scientific Affairs, AMA. (1995). Dehydration: Evaluation and management in older adults, journal of the American Medical Association, 274, 1552-1556.
Outcomes for Hospitalized Elders Experiencing an Acute Confusion Episode
Indicators of Dehydration in Acutely III Elderly Patients