Journal of Gerontological Nursing

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UNRECOGNIZED Chronic Dehydration in Older Adults: Examining Prevalence Rate and Risk Factors

Jill A Bennett, PhD, RN; Valorie Thomas, MS, RN; Barbara Riegel, DNSc, RN, CS, FAAN

Abstract

ABSTRACT

Dehydration has serious consequences for older adults, including increased risk of illness or death. This retrospective review of medical records describes the prevalence, assessment, and risk factors for chronic dehydration in 185 older adults who visited an emergency department in June 2000. Results showed chronic dehydration was present in 89 (48%) patients. Physicians documented assessment for signs of dehydration in 23 (26%) of the dehydrated older adults, but no independent assessments for dehydration were recorded by nurses. These findings indicate many older adults may suffer from unrecognized dehydration, and nurses should be alert to the possibility that dehydration may be present in community-dwelling older adults as well as those who live in residential facilities.

Abstract

ABSTRACT

Dehydration has serious consequences for older adults, including increased risk of illness or death. This retrospective review of medical records describes the prevalence, assessment, and risk factors for chronic dehydration in 185 older adults who visited an emergency department in June 2000. Results showed chronic dehydration was present in 89 (48%) patients. Physicians documented assessment for signs of dehydration in 23 (26%) of the dehydrated older adults, but no independent assessments for dehydration were recorded by nurses. These findings indicate many older adults may suffer from unrecognized dehydration, and nurses should be alert to the possibility that dehydration may be present in community-dwelling older adults as well as those who live in residential facilities.

Chronic dehydration is a common but preventable condition with serious consequences for older adults, including medication toxicity (Chernoff, 1994), loss of muscle function (Askew, 1 996), depressed state of consciousness (Snyder, Feigal, & Arieff, 1987), renal failure and seizures (Lavizzo-Mourey, 1987), and hypo- or hyperthermia (Chernoff, 1994). Serious infections also are especially common in dehydrated older adults (Warren et al., 1994).

Acute dehydration may be experienced by individuals of all ages during illness. Acute dehydration is a loss of water and sodium, often caused by vomiting, diarrhea, sweating, blood loss, or fluid accumulation in body spaces where it cannot be drawn back into circulation.

On the other hand, chronic dehydration is a fluid imbalance of longer duration that in older adults is usually caused by insufficient fluid intake (Armstrong-Esther, Browne, Armstrong-Esther, & Sander, 1996; Chidester & Spangler, 1997; Kay serJones, Schell, Porter, Barbaccia, & Shaw, 1999; Weinberg, Minaker, & Council on Scientific Affairs, American Medical Association, 1995). Chronic dehydration causes fluid deficits within the cells, leading to altered absorption of medications, delirium, weakness, fatigue, exacerbation of medical conditions, and increased risk of death. Reported death rates for older adults admitted to the hospital for acute and chronic dehydration range from 18% to 71% (Molaschi et al., 1997; Warren et al., 1994), and mortality may be seven times higher than for patients who are not dehydrated (Snyder et al., 1987).

Dehydration in elderly patients is common and costly. The annual cost of care for older adults with a primary diagnosis of dehydration has been estimated at more than $1 billion (Burger, Kayser-Jones, & Bell, 2000; Weinberg et al., 1995), although this may be an underestimate because many cases of dehydration are unrecognized.

Using Medicare records, Warren et al. (1994) found only 6.7% of hospitalized older adults were dehydrated, based on an analysis of International Classification of Diseases-9 ICD-9) diagnoses of dehydration. Other investigators reported dehydration rates of 43% (Snyder et al., 1987) and 51% (Himmelstein, Jones, & Woolhandler, 1983) when blood values were used to make the diagnosis. This discrepancy suggests charted ICD-9 diagnoses of dehydration in older adults may underestimate the actual prevalence of dehydration. Dehydration may be particularly prevalent in nursing homes (Armstrong-Esther et al., 1996; KayserJones et al., 1999; Lavizzo-Mourey, Johnson, & Stolley, 1988; Weinberg et al., 1994), where low intake of fluids was observed in as many as 50% to 90% of residents (Chidester & Spangler, 1997). Thus, dehydration also has been documented to be a problem in hospitalized older adults, and low fluid intake has been documented to be a problem among nursing home residents. However, whether chronic dehydration is common in community-dwelling older adults is unknown.

In summary, studies on dehydration in hospitalized older adults have reported varying rates, depending on how dehydration was measured. Observational studies of older adults in nursing homes have shown fluid intake is generally low, but few nursing home studies have used blood values to measure dehydration.

The purpose of this study was to examine the prevalence of chronic dehydration in non-hospitalized older adults by measuring blood values of older patients who visited a hospital emergency department during a 1month period. Secondary purposes were to describe the documented assessments for dehydration by physicians and nurses in the emergency department and to determine the risk factors associated with chronic dehydration in older adults.

METHODS

This descriptive, retrospective study of 1 85 older adults who visited a hospital emergency department during June 2000 was conducted using data from medical records. The diagnosis of dehydration was determined using laboratory data available in the records.

Sample

The sample for this study consisted of patients age 75 or older who were admitted to the hospital or sent home from the emergency department of a private, not-for-profit urban hospital in southern California during June 2000. The hospital administrative database identified 270 potentially eligible subjects, whose written medical records were examined for inclusion in the study; patients were not contacted directly.

Records were excluded for the following reasons:

* Emergency department visit was the second or third visit during June by the same patient (« = 20).

* Patient had blood laboratory values of creatinine > 5 mg/dl or glucose > 300 mg/dl, which are indicative of renal dysfunction or uncontrolled diabetes mellitus and would make determination of dehydration difficult (n = 7).

* Patient had received > 100 ml of fluid during transportation to the hospital that would make determination of hydration status prior to emergency department admission difficult n = 1).

* Medical record did not contain laboratory blood values to measure dehydration (n - 28).

* Medical record could not be located (« = 29).

Procedures and Measures

Data reflecting the emergency department visit were collected by two research assistants, a registered nurse and a licensed vocational nurse, using a chart review tool developed for this study. The two raters agreed on 95.4% of 260 entries in five charts (52 variables per chart) used to test interrater reliability. The five charts used for this purpose were reviewed prior to beginning the study and were not included in the study sample. The chart review tool and study procedures were approved by the Institutional Review Board of both the hospital and the academic institution of the investigators.

Prevalence of dehydration. Dehydration was defined as a ratio of blood urea nitrogen to creatinine (BUN:Cr) > 20:1. This measure is consistent with other studies of dehydration in older adults (Gross et al., 1992; Lindeman et al., 2000; Simmons, Alessi, & Schnelle, 2001) and conforms to standard guidelines for interpreting the results of diagnostic tests.

Table

TABLE 1STATISTICALLY SIGNIFICANT DIFFERENCES IN CLINICAL SIGNS AND RISK FACTORS BETWEEN DEHYDRATED AND NONDEHYDRATED OLDER ADULTS WHO VISITED THE EMERGENCY DEPARTMENT (N = 185)

TABLE 1

STATISTICALLY SIGNIFICANT DIFFERENCES IN CLINICAL SIGNS AND RISK FACTORS BETWEEN DEHYDRATED AND NONDEHYDRATED OLDER ADULTS WHO VISITED THE EMERGENCY DEPARTMENT (N = 185)

BUN is a gross index of urea excretion that may increase in older adults when their kidneys cannot concentrate urine adequately. Creatinine is a by-product in the breakdown of muscle creatine phosphate that increases if kidney function is impaired. In older adults, an increase in both BUN and creatinine is indicative of kidney dysfunction, but an increase in the BUN.Cr ratio suggests chronic dehydration because urea, reabsorbed through the distal tubule of the nephron, is more sensitive to dehydration than creatinine, which is reabsorbed in the proximal tubule (Lindeman et al., 2000).

Assessment of dehydration. The written notes of physicians and nurses were evaluated separately to determine whether clinical signs of dehydration were assessed. All commonly used clinical signs of dehydration (i.e., sunken eyes, coated or furry tongue, longitudinal furrows on tongue, dry tongue, dry oral membranes, upper body muscle weakness, poor skin turgor, urine color) were included regardless of their appropriateness for assessment in older adults.

Risk factors for dehydration. A variety of risk factors for dehydration were measured, based on the literature on dehydration in nursing homes and suggested by the clinical experience of the authors. Age, gender, and place of residence (residential facility or community) were recorded from information in the admission face sheet of the medical record or in a physician's or nurse's written note.

Ability to speak English also was hypothesized as a risk factor, especially in residential facilities where fluid intake may depend on communication with caregivers. This factor was recorded only from a physician's or nurse's note in the patient's history because earlier studies have shown language information on the admission face sheet is often inaccurate (Ellis et al., 2001).

Ambulation, which may affect an older adult's ability to eat or drink without help, was classified according to documentation in the medical record as:

* Walks without assistance.

* Walks only with an assistive device.

* Uses a wheelchair.

* Bedbound.

Medical conditions, which may affect hydration through medications or symptoms, were recorded by extracting evidence from physicians' and nurses' notes, using a list of words that described 15 chronic medical conditions. Orientation and level of consciousness, which is likely to make fluid intake less frequent, were recorded from physicians' or nurses' notes. AU risk factor variables were coded as unknown if their values could not be determined from the written medical record.

Statistical Analysis

The prevalence and assessment of dehydration were described as proportions. Physiological characteristics and risk factors were compared in dehydrated and non-dehydrated groups using descriptive statistics. The chi-square test was used to test the significance of group differences of each categorical variable, and independent-group t tests were used to compare dehydrated and non-dehydrated groups on continuous variables. Logistic regression models were developed to test the odds of dehydration associated with risk factor variables. All analyses were conducted using Statistical Package for Social Sciences version 10.1 (SPSS Inc., Chicago, IL).

RESULTS

The sample ranged in age from 75 to 100 years (mean age, 83 ± 5.2 years). Most of the older adults in the sample were English-speaking (88%) and female (62%), and most (80%) resided in the community rather than in a residential facility. An acute infection was present in 38% of the sample; 21% had a urinary tract infection (UTI), 8% had pneumonia, 5% had both UTI and pneumonia, and 4% had other infections, such as an upper respiratory infection or wound infection.

Prevalence of Dehydration

In this sample, 89 (48%) of 185 older adults had a BUN:Cr ratio > 20:1, indicating they were dehydrated on admission to the emergency department. Older adults from residential facilities were most likely to be dehydrated (65%), although many (44%) of the community-dwelling older adults also were dehydrated.

Hypernatremic dehydration was present in five patients who had a serum sodium level > 145 mEq/L, and severe hypernatremic dehydration was present in two patients who had serum sodium levels > 148 mEq/L. Both of the patients with severe hypernatremic dehydration, who resided in skilled nursing facilities, had pneumonia accompanied by severely decreased levels of consciousness and very low blood pressures.

Assessment of Dehydration

Of the 89 dehydrated older adults with a BUN:Cr ratio > 20:1, 23 (26%) had a documented assessment for signs of dehydration in the emergency department physicians' written medical record notes. Physicians noted dry oral membranes in 18 (20%), upper body muscle weakness in 2 (2%), and skin turgor in 3 (3%). In the charts of these 89 dehydrated older adults, there were no documented assessments by nurses for clinical signs of dehydration.

Physiological Characteristics and Risk Factors for Dehydration

Dehydrated older adults had a significantly higher mean BUN level compared to non-dehydrated older adults (Table 1). Mean serum creatinine level was similar in both groups. Blood pressure was lower in dehydrated older adults, but other clinical signs were not different. Diuretics were routinely taken by 59 (32%) of the 1 85 older adults, but the proportion taking diuretics was similar in both the dehydrated and non-dehydrated groups. Two individuals were taking two diuretics and neither was dehydrated.

Figure. Distribution of blood urea nitrogen to creatinine (BUN:Cr) ratio quartiles for four characteristics of older adults who visited the emergency department of an urban hospital (N= 185). BUN:Cr ratio quartiles: 1 = 0 to 15.19, 2 = 15.2 to 20, 3 = 20.1 to 26.5, and 4 = 26.6 to 65; quartiles 3 and 4 represent dehydration.

Figure. Distribution of blood urea nitrogen to creatinine (BUN:Cr) ratio quartiles for four characteristics of older adults who visited the emergency department of an urban hospital (N= 185). BUN:Cr ratio quartiles: 1 = 0 to 15.19, 2 = 15.2 to 20, 3 = 20.1 to 26.5, and 4 = 26.6 to 65; quartiles 3 and 4 represent dehydration.

Older adults in the dehydrated group were significantly more likely to live in a residential facility, need an assistive device or wheelchair for mobility, be disoriented, and have more than four chronic medical conditions (Table 1). There was a similar proportion of individuals with acute infections in the two groups.

The five most common chronic medical conditions in the dehydrated group were cardiovascular conditions (53%), stroke (29%), diabetes (28%), arthritis or osteoporosis (25%), and dementia (19%). The five most common chronic medical conditions in the non-dehydrated group were cardiovascular conditions (43%), gastrointestinal conditions (23%), arthritis or osteoporosis (23%), pulmonary conditions (18%), and stroke (16%).

Table

TABLE 2LOGISTIC REGRESSION ANALYSIS OF ODDS OF MEMBERSHIP IN DEHYDRATED GROUP ACCORDING TO PERSONAL, FUNCTIONAL, AND MEDICAL CHARACTERISTICS (N = 140)*

TABLE 2

LOGISTIC REGRESSION ANALYSIS OF ODDS OF MEMBERSHIP IN DEHYDRATED GROUP ACCORDING TO PERSONAL, FUNCTIONAL, AND MEDICAL CHARACTERISTICS (N = 140)*

The Figure shows the distribution of BUNrCr ratio quartiles for the four characteristics that were significantly different between the dehydrated and non-dehydrated groups in the univariate analysis:

* Living environment.

* Ambulation.

* Medical conditions.

* Orientation.

The highest quartile of BUN.Cr ratio (26.6 to 65) included the largest proportion of older adults from residential facilities, older adults who could not walk without assistance, older adults who were disoriented, and older adults with more than four chronic medical conditions.

Logistic regression analysis of all cases without missing data was used to determine which of the hypothesized risk factors increased the likelihood of dehydration in the context of a model that contained all of the other risk factors. Risk factors were selected for analysis if there was empirical evidence in the literature that each was associated with dehydration in older adults. Results showed female gender and disorientation were the only risk factors independently associated with dehydration in a model that included all of the risk factors (Table 2).

DISCUSSION

The results of this study demonstrate dehydration is common in community-dwelling older adults as well as in older adults living in residential facilities. The finding that dehydration was common in this sample of adults age 75 and older corroborates an earlier study that found dehydration is a more common emergency department diagnosis in older adults than in younger adults (Ciccone, Allegra, Cochrane, Cody, & Roche, 1998).

The finding that 27% of the older adults with dehydration in this sample lived in residential facilities is less than the 51% reported by Himmelstein et al. (1983), possibly because the current study used a single serum value taken on entry to the emergency department to measure dehydration, while Himmelstein et al. used serum values on two or more occasions during hospitalization to measure dehydration. Thus, the earlier study may have included cases of dehydration that developed in the hospital; Borra, Beredo, and Kleinfeld (1995) and Snyder et al. (1987) reported as many as 40% of dehydration cases develop after a patient is admitted to the hospital. The finding of the current study that the majority (65%) of older adults from residential facilities were dehydrated before they came to the emergency department is similar to the 53% reported by Lavizzo-Mourey et al. (1988) who used a stricter criterion to measure dehydration (BUN:Cr ratio > 25 or serum sodium level > 150).

Earlier studies on dehydration in older adults have used BUNrCr ratio > 20:1 or > 25:1 to measure chronic dehydration, sometimes as sole measure (Gross et al., 1992; Lavizzo-Mourey et al., 1988; Lindeman et al., 2000; Simmons et al., 2001) and sometimes in combination with a serum sodium level > 145 to 150 mEq/L (Himmelstein et al., 1983; Weinberg et al., 1 994). The prevalence of dehydration in this study also was calculated using the more conservative criterion (BUN:Cr ratio > 25:1) used in some early studies. By this measure, 51 (27%) patients in the sample were classified as dehydrated. Thus, even by a more conservative measure, a substantial proportion of the older adults in this sample who visited the emergency department were dehydrated.

Some researchers have used serum sodium level as a sole measure of dehydration (Macdonald, McConnell, Stephen, & Dunnigan, 1989; Snyder et al., 1987). The rate of hypernatremic dehydration in this study was similar to that in other studies of patients of similar age. In this study, 5 (2.7%) patients had serum sodium levels > 145 mEq/L, a similar proportion to the 2.9% found in hospitalized patients by Molaschi et al. (1997).

Only 2 (1 .1 %) of the patients in this sample had severe hypernatremic dehydration shown by serum sodium levels > 148 mEq/L; this proportion is similar to the .5% to .6% of hospitalized older adults reported by Himmelstein et al. (1983) and Snyder et al. (1987). Both of the patients in this sample were diagnosed with severe dehydration by the physician in the emergency department. While severe hypernatremic dehydration is an acute condition that is likely to be recognized and treated, recognition and treatment of chronic dehydration may be even more important because it affects the physical and cognitive wellbeing of a large number of older adults.

Other investigators have found an association between acute infections and dehydration (Weinberg et al., 1994). Therefore, some might argue that the rates of dehydration found in the current study conducted in the emergency department were the result of an acute event rather than a chronic condition. However, the presence of a UTI, pneumonia, or other acute infection was not associated with dehydration, suggesting there were other etiologies for the dehydration present in almost half of the older adults in this study, perhaps low intake of fluids.

Although patients were excluded if they had serum values characteristic of renal failure and uncontrolled diabetes, it was not possible to eliminate patients who may have experienced rapid free water loss due to extreme vomiting and diarrhea. Thus, some cases of acute dehydration due to illness rather than chronic pre-existing dehydration may have been included.

The univariate analyses revealed older adults in the dehydrated group were more likely to live in a residential facility, be non-ambulatory, be disoriented, and have more than four chronic medical conditions. Only female gender and disorientation were significantly associated with dehydration in simultaneous logistic regression models, perhaps because the risk factors were not sufficiently independent of each other. Further studies are needed to conclusively identify the major risk factors for dehydration.

Physicians recorded assessments of clinical signs of dehydration in relatively few of the older adults presenting to the emergency department, and there were no recorded assessments for dehydration by nurses. The most common assessments were dry oral membranes and upper body weakness, which have been shown to be good clinical indicators of dehydration in older adults (Gross et al., 1992; McGee, Abernethy, & Simel, 1999). In three cases, physicians assessed for skin turgor, which is unreliable as a sign of dehydration in older adults (Gross et al., 1992; McGee et al., 1999; Weinberg et al., 1995).

The small number of recorded assessments may reflect physicians' and nurses' knowledge that symptoms of dehydration in older adults may be vague, not useful for diagnosis of dehydration, and difficult to distinguish from clinical signs of other medical conditions (Chernoff, 1994; Gross et al., 1992; McGee et al., 1999; Weinberg et al., 1995). In fact, many commonly accepted clinical signs of dehydration, such as rapid heart rate or urine specific gravity were absent in the dehydrated older adults in the study sample, thus the lack of recorded assessments may be understandable. Even if assessments were made, documentation may suffer when the emergency department is busy, a factor that could not be determined in this study.

LIMITATIONS

The accuracy of written medical records as a source of data may be questioned. Although the measure of dehydration was based on laboratory blood values that should be accurate, the patient characteristics assessed as possible risk factors came largely from physicians' notes, which depend on how well the patient or family communicated with the physician, how much time the physician had for the interview, and other factors.

In addition, the study sample consisted of emergency department discharges during a single month, so it is possible that dehydration data from other months would vary seasonally. The findings suggest an investigation of dehydration during a longer time period is warranted. If prevalence throughout the year is as high as that found in this study, chronic dehydration in older adults may be an important issue to address in the emergency department and elsewhere.

IMPLICATIONS FOR NURSING

This study of older adults who visited an emergency department during 1 month of the year showed 48% had blood values indicative of chronic dehydration. Future research in other settings is needed to confirm the proportion of dehydrated older adults found in this study is typical of the general older adult population, but the findings suggest chronic dehydration may be common, regardless of whether older adults live in the community or in a residential facility.

The dehydrated older adults in this study did not display clinical signs of dehydration, such as elevated heart rate or high urine specific gravity. In older adults, commonly used signs of dehydration, such as skin turgor, may not be useful. Thus, nurses in all settings should be aware of the possibility of chronic dehydration in older adults, even in the absence of clinical signs.

Prevention of dehydration is an important task for gerontological nurses. Talking to individuals and families about the dangers of dehydration and suggesting strategies to overcome barriers to drinking sufficient fluids may be important interventions that prevent adverse outcomes, including increased risk of death, associated with dehydration in older adults.

REFERENCES

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TABLE 1

STATISTICALLY SIGNIFICANT DIFFERENCES IN CLINICAL SIGNS AND RISK FACTORS BETWEEN DEHYDRATED AND NONDEHYDRATED OLDER ADULTS WHO VISITED THE EMERGENCY DEPARTMENT (N = 185)

TABLE 2

LOGISTIC REGRESSION ANALYSIS OF ODDS OF MEMBERSHIP IN DEHYDRATED GROUP ACCORDING TO PERSONAL, FUNCTIONAL, AND MEDICAL CHARACTERISTICS (N = 140)*

10.3928/0098-9134-20041101-09

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