Journal of Gerontological Nursing

CNE Article 

Associations Between Dehydration, Cognitive Impairment, and Frailty in Older Hospitalized Patients: An Exploratory Study

Judy McCrow, PhD, RN; Margaret Morton, RN; Catherine Travers, PhD; Keren Harvey, MBBS, FRACP; Eamonn Eeles, MBBS, FRACP

Abstract

The current exploratory study (a) assessed the prevalence of dehydration in older adults (age ≤60 years) with and without cognitive impairment (CI) admitted to the hospital; and (b) examined associations between dehydration, CI, and frailty. Forty-four patients participated and dehydration was assessed within 24 hours of admission and at Day 4 or discharge (whichever occurred first). Patients' cognitive function and frailty statuses were assessed using validated instruments. Twenty-seven (61%) patients had CI and 61% were frail. Prevalence of dehydration at admission was 29% (n = 12) and 19% (n = 6) at study exit, and dehydration status did not differ according to CI or frailty status. However, within the non-CI group, significantly more frail than fit patients were dehydrated at admission (p = 0.03). Findings indicate dehydration is common among older hospitalized patients and that frailty may increase the risk for dehydration in cognitively intact older adults. [Journal of Gerontological Nursing, 42(5), 19–27.]

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1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. To obtain contact hours you must:

  1. Read the article, “Associations Between Dehydration, Cognitive Impairment, and Frailty in Older Hospitalized Patients: An Exploratory Study” found on pages 19–27, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.
  2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.
  3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until April 30, 2019.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Activity Objectives
  1. Describe the incidence of dehydration in older hospitalized patients.
  2. Identify risk and management strategies related to dehydration in older hospitalized patients.
Disclosure Statement

Neither the planners nor the author have any conflicts of interest to disclose.

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Abstract

The current exploratory study (a) assessed the prevalence of dehydration in older adults (age ≤60 years) with and without cognitive impairment (CI) admitted to the hospital; and (b) examined associations between dehydration, CI, and frailty. Forty-four patients participated and dehydration was assessed within 24 hours of admission and at Day 4 or discharge (whichever occurred first). Patients' cognitive function and frailty statuses were assessed using validated instruments. Twenty-seven (61%) patients had CI and 61% were frail. Prevalence of dehydration at admission was 29% (n = 12) and 19% (n = 6) at study exit, and dehydration status did not differ according to CI or frailty status. However, within the non-CI group, significantly more frail than fit patients were dehydrated at admission (p = 0.03). Findings indicate dehydration is common among older hospitalized patients and that frailty may increase the risk for dehydration in cognitively intact older adults. [Journal of Gerontological Nursing, 42(5), 19–27.]

How to Obtain Contact Hours by Reading This Article
Instructions

1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. To obtain contact hours you must:

  1. Read the article, “Associations Between Dehydration, Cognitive Impairment, and Frailty in Older Hospitalized Patients: An Exploratory Study” found on pages 19–27, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.
  2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.
  3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until April 30, 2019.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Activity Objectives
  1. Describe the incidence of dehydration in older hospitalized patients.
  2. Identify risk and management strategies related to dehydration in older hospitalized patients.
Disclosure Statement

Neither the planners nor the author have any conflicts of interest to disclose.

Do you want to Participate in the CNE activity?

Dehydration “refers to the loss of body water, with or without salt, greater than the body can replace it” (Thomas et al., 2008). Dehydration is common in older adults and associated with a range of adverse outcomes, including falls, fractures, functional decline, constipation, delayed wound healing, confusion, delirium, medication toxicity, and urinary and respiratory tract infections (Mentes, 2006a; Pash, Parikh, & Hashemi, 2014). Hospitalized older adults with dehydration also have longer lengths of stay, increased mortality, and significantly higher hospital costs compared to patients without dehydration (Pash et al., 2014).

Although the prevalence of dehydration in older hospitalized patients has been infrequently studied, rates of 10% to 44% have been reported (El-Skarkawy, Sahota, Maughan, & Lobo, 2014; Fortes et al., 2015; Glover et al., 2014). Glover et al. (2014) reported that 10% of patients 70 and older (n = 197) with an unscheduled hospital admission were dehydrated at admission (based on chart review) compared to 21% in a subset of patients who were reviewed by a geriatrician following admission. More recently, El-Sharkawy et al. (2014) reported, in a prospective study conducted in the United Kingdom, that 40% of patients 65 and older were dehydrated at hospital admission. Although methodological differences in the samples recruited and dehydration measures used most likely accounted for the different prevalence rates, these studies indicate dehydration is an important issue among hospitalized older adults.

Dementia also appears to increase risk of dehydration in the hospital, with several studies reporting higher rates of dehydration in older patients with dementia compared to same-aged patients without dementia (Phelan, Borson, Grothaus, Balch, & Larson, 2012; Zuliani et al., 2012). Chen, Dai, Yen, Huang, and Wang (2010) reported that cognitive impairment (CI) increased the risk of dehydration in 455 older Taiwanese patients (age ≤65 years). However, their assessment of dehydration was based on the ratio of serum urea nitrogen to creatinine ratio, which should not be used as a sole measure of dehydration (Thomas et al., 2008). Rather, it has been suggested that, in the absence of a gold standard test of dehydration, serum or plasma osmolarity or a change in body weight over 7 days should be the reference standard for dehydration (Hooper et al., 2015).

Although the prevalence of dehydration has been reported to be higher in older patients with dementia or CI in the hospital setting, little is known about the incidence of dehydration post-admission and the course of dehydration in these patients. It is conceivable that patients with dementia or CI may be at increased risk of developing dehydration in the unfamiliar hospital setting, which often increases their confusion (Gladman et al., 2012). Hence, the aims of the current study were to assess the prevalence of dehydration in medically ill older patients with and without CI at hospital admission and assess its course over the first 4 days of hospitalization. Additional aims were to explore potential predictors and examine any associations between dehydration, CI, and frailty (with which CI is strongly associated [Kumala, Nykänen, Mänty, & Hartikainen, 2014]).

A 4-day timeframe was elected, as the average length of stay in acute public hospitals in Queensland was 5 days in 2012–2013 (Australian Institute of Health and Welfare, 2014); therefore, a 4-day timeframe would be sufficient to capture most inpatients' data during their hospital stay.

Method

Design

A prospective study of patients age 60 and older admitted to the internal medical unit of a large tertiary referral hospital in Southeast Queensland, Australia was conducted. Recruitment occurred between July 2013 and November 2014.

Ethics

Ethical approval was received from the university's and hospital's human research ethics committees prior to commencement. Informed written consent was obtained from all participants (or their legal guardians) prior to participation in the study.

Participants

A convenience sample of patients 60 and older was recruited for the study. Sample size was determined on logistic grounds and, given it was a pilot study, a sample of 50 was considered realistic within the timeframe. Patients were eligible for inclusion if they were: 60 or older, English speaking, and research staff were available to collect all baseline data within the first 24 hours of admission. Because it was not possible for research staff to collect discharge data on weekends, recruitment was restricted to between Sunday afternoons and Tuesday evenings. Exclusion criteria included: unstable congestive heart failure, chronic kidney disease stage 5, being classified as nil by mouth on admission, and having less than a 24-hour expected length of stay.

Measures

Trained research assistants collected demographic and clinical information, including age, gender, living arrangements (community-dwelling or living in a residential aged care facility), comorbidities, self- or informant-reported change in functional level, and medication use, from each participant or his/her proxy. They also collected patients' height and weight measurements at baseline and used interview data and information from patients' charts to complete the original Dehydration Risk Appraisal Checklist (DRAC; Mentes & Kang, 1998) to assess dehydration risk. The DRAC is a 31-item checklist of factors demonstrated to increase an individual's dehydration risk and includes personal and clinical characteristics (DRAC-A), medical conditions (DRAC-B), medications (DRAC-C), dietary and fluid intake behaviors (DRAC-D), and laboratory findings (DRAC-E). The total number of risk factors identified is summed (DRAC-Total) to yield an overall score, with higher scores indicative of greater dehydration risk.

The Rowland Universal Dementia Assessment Scale (RUDAS; Storey, Rowland, Basic, Conforti, & Dickson, 2004) was administered to assess participants' cognitive functioning. The RUDAS is a brief cognitive screening test designed to minimize the effects of cultural learning and language diversity on performance. It yields a score of 0 to 30, with scores ≤22 indicative of CI (unless the low score is a consequence of another disability, such as visual impairment). It has demonstrated high sensitivity (89%) and specificity (98%) for identifying CI (Storey et al., 2004). In the current study, patients with RUDAS scores ≤22 were classified as having CI, whereas those with RUDAS scores ≥23 were considered cognitively intact.

The Confusion Assessment Method (CAM) was administered to assess patients for delirium. The CAM assesses the presence of the key features of delirium and includes a diagnostic algorithm based on four essential criteria: (a) acute onset and fluctuating course, (b) inattention, (c) disorganized thinking, and (d) altered level of consciousness (Inouye et al., 1990). The CAM requires only 5 to 10 minutes to administer and has shown high sensitivity (94% to 100%) and specificity (89% to 95%) for detecting delirium, as well as high interrater reliability (0.81 to 1) (Wei, Fearing, Sternberg, & Inouye, 2008).

The Clinical Frailty Scale (CFS; Rockwood et al., 2005) was completed for each participant as a measure of frailty or vulnerability, which is a consequence of age-related decline in multiple physiological systems over an individual's lifespan and is highly predictive of mortality and other adverse outcomes (Clegg, Young, Iliffe, Rikkert, & Rockwood, 2013). The CFS is a 7-point scale that classifies an individual according to intervals ranging from very fit to severely frail. Clinicians use their judgement to classify the patient and consider all relevant clinical information, including comorbidities, CI, and functional ability, to make their decision.

Hydration Status

Dehydration has been defined as a loss or removal of fluid from the body that occurs when fluid intake fails to fully replace fluid losses (Brooker, 2008) and, in the current study, dehydration was determined by either elevated calculated serum osmolality readings or clinical assessment.

Elevated serum osmolality constitutes the most commonly used reference standard (Thomas et al., 2008) for dehydration and patients with serum osmolality readings ≥295 mmol/L were considered dehydrated. Hence, this definition included impending water loss dehydration (serum osmolality 295 to 300 mmol/L) and current dehydration (serum osmolality >300 mmol/L) (Thomas et al., 2008).

Patients were also considered dehydrated if indicated by clinical assessment. Clinical assessment of dehydration is widely used in hospital settings, and assessments used at the study hospital have previously been validated as practical and reliable indicators of dehydration in hospitalized older adults (Vivanti, Harvey, Ash, & Battistutta, 2008).

Clinical Assessments

Clinical assessments were performed at baseline and study exit (Day 4 of the admission or discharge from hospital, whichever occurred first), and included: lying and standing blood pressure (when the patient was able, blood pressure was measured first when lying down and then in an upright position for at least 2 minutes), pulse rate, visual assessment of jugular venous pressure, tissue turgor (assessed by pinching the skin at the dorsum of the hand and over the manubrium, normal tissue turgor indicated by disappearance of the skin fold in ≤2 seconds), self-reported thirst, inspection of oral mucous membranes for dryness, inspection of tongue for dryness, and longitudinal furrows and reported urine specific gravity. These assessments were performed by experienced geriatricians (E.E., K.H.) and baseline data were collected within 24 hours of the patient's admission.

Calculated serum osmolality samples were collected at baseline and study exit.

If a patient was suspected of being dehydrated following clinical assessments, hospital staff were informed.

Data Analysis

Chi-square tests were used to compare the dehydration status of patients at admission and exit according to CI (CI versus no CI) and frailty (fit versus frail) status, and within the CI and non-CI groups according to frailty status. Multivariate logistic regression analyses were performed using the forward likelihood ratio entry method to identify independent variables associated with dehydration at admission and study exit. Variables assessed as possible predictors included age, gender, cognitive status (CI versus no CI), RUDAS scores, Clinical Frailty Scale scores, dichotomized Clinical Frailty Scale Scores (fit included scores ranging from 1 to 4 and frail included scores ranging from 5 to 7, where frail patients included those who were mildly, moderately, or severely frail and fit patients included all others), body mass index, number of comorbidities, DRAC subscale and total scores, administration of intravenous (IV) fluids (yes/no), and psychotropic medication use (yes/no). Dehydration at admission was also assessed as a potential predictor of dehydration at exit.

All data analyses were performed using SPSS for Windows version 21.

Results

Of 68 patients admitted to the hospital who met all eligibility criteria, 45 initially agreed to participate in the study, representing a response rate of 66%. Twenty-three patients (or their relatives) declined participation, whereas one participant was withdrawn from the study soon after consenting due to an acute deterioration in medical status. Thus, the final sample comprised 44 patients (Figure).


            Study flowchart.

Figure.

Study flowchart.

Baseline Characteristics of Patients

Sample characteristics at baseline are reported in Table 1, which shows the majority of participants were female (n = 24, 55%), with an average age of 81 years (SD = 8.5 years). The majority of participants (n = 41, 93%) lived in the community; only 3 (7%) patients lived in residential aged care facilities. More than one half of participants were cognitively impaired (n = 27, 61%) and considered frail (n = 27, 61%), with 18 (41%) patients being both frail and having CI. Of patients with CI, two (7.4%) had CI secondary to delirium and four (14.8%) had delirium superimposed on CI. Several differences were evident between the CI and non-CI group at baseline, including significantly more medical comorbidities and risks for dehydration in the CI group compared to the non-CI group (Table 1). Overall, the average length of stay was 4.7 days (SD = 3.5) and 30 patients (70%) were discharged by study exit.


            Characteristics of Participants With and Without Cognitive Impairment (CI) At Baseline (N = 44)
            Characteristics of Participants With and Without Cognitive Impairment (CI) At Baseline (N = 44)

Table 1:

Characteristics of Participants With and Without Cognitive Impairment (CI) At Baseline (N = 44)

Dehydration

Approximately one third of patients (29%, n = 12) were identified as being dehydrated at admission—27% (n = 11) on the basis of the clinical assessment alone and 29% (n = 12) when serum osmolality results were included. This result decreased to 21% (n = 9) at study exit and one half of patients considered dehydrated at admission (50%) remained dehydrated at study exit. Approximately one third of patients (n = 15, 34%) received IV fluids while in the hospital, although this did not differ according to patients' dehydration status at admission (6 patients [50%] with dehydration received IV fluids versus 8 [26%] without dehydration; chi-square = 2.3, df = 1, p = 0.13) or discharge (4 patients [44.4%] with dehydration received IV fluids versus 8 [30%] without dehydration; chi-square = 0.67, df = 1, p = 0.41).

There was no difference in dehydration status according to CI status at admission or study exit and dehydration status did not differ according to frailty status (fit versus frail) at either time point (Table 2). Similarly, there was no difference in the dehydration status of fit and frail patients within the CI group at admission (chi-square = 3.13, df = 1, p = 0.08) or study exit (chi-square = 0.06, df = 1, p = 0.81). However, within the cognitively intact group, frail patients (n = 5) were significantly more likely to be dehydrated at admission than fit patients (n = 0) (chi-square = 5, df = 1, p = 0.03), and although more cognitively intact, frail patients (n = 4) remained dehydrated at study exit compared to fit patients (n = 0), the difference was nonsignificant at study exit (chi-square = 0.621, df = 1, p = 0.06).


            Dehydration Status of Patients with and without Cognitive Impairment (CI), and with and without Frailty at Hospital Admission and Study Exit

Table 2:

Dehydration Status of Patients with and without Cognitive Impairment (CI), and with and without Frailty at Hospital Admission and Study Exit

Predictors of Dehydration

Results of logistic regression revealed no variable independently predicted dehydration at admission to hospital, whereas dehydration at admission significantly predicted exit dehydration (odds ratio = 0.07, 95% confidence interval = [0.01, 0.51], p = 0.01).

Discussion

Results of the current exploratory study indicated a substantial proportion of medically ill older patients were dehydrated at admission to the hospital (approximately one third) and study exit (approximately one fifth). However, the actual percentage may have been higher as some discharge data were missing due to research staff being unavailable to collect these data at the time of discharge. The dehydration rate of approximately 30% at admission is consistent with rates reported in other prevalence studies (i.e., 10% to 40%) and confirms the high prevalence of dehydration among older patients admitted to the hospital (El-Sharkawy et al., 2014; Fortes et al., 2015; Glover et al., 2014). The high prevalence of dehydration in this sample and the unchanged dehydration status of approximately one half of patients has important implications for nursing practice, including the need to increase nurses' awareness of the importance of dehydration as an issue for hospitalized older patients, particularly those who are frail. These findings also highlight the importance of routinely assessing older patients' hydration status at admission to the hospital, particularly those who are frail, and for this to be regularly monitored throughout their stay to optimize care for this patient group.

Prevalence of CI in this relatively small sample was high (61.4%), although no relationship was found between cognitive status and dehydration—a finding that differs from several previous studies that have reported dementia and CI to be risk factors for dehydration in hospitalized older adults (Chen et al., 2010; Phelan et al., 2012; Zuliani et al., 2012). However, those studies were based on larger samples (N = 1,905, 51,838, and 455, respectively) and it is likely that the current study's small sample accounted (at least in part) for the failure to find any relationship between CI and dehydration.

It was found that of cognitively intact patients, frail patients had significantly higher dehydration rates at admission compared to fit patients, and appeared more likely to remain dehydrated at study exit. By comparison, no difference was found between the prevalence of dehydration among fit and frail patients within the CI group. This finding suggests frailty may be a risk factor for dehydration in cognitively intact older adults and is consistent with the increased risk frailty confers for a wide range of other adverse outcomes, including an increased risk of falls, fractures, functional decline, and mortality (Milte & Crotty, 2014)—outcomes associated with dehydration (Mentes, 2006a; Pash et al., 2014).

The cognitively intact, frail patients found to be dehydrated may reflect the subgroup of patients who cannot drink, identified by Mentes (2006b) in her typology of hydration problems in nursing home residents. This group includes patients who are frail or have physical dependencies and who rely upon assistance by nursing home staff to maintain adequate hydration. The finding that four frail, cognitively intact patients remained dehydrated from admission to study exit (4 days later) raises concerns that adequate assistance may not have been provided to these patients. These findings indicate that, in addition to raising the profile of hydration management as an important issue for older hospitalized patients, nurses must regularly monitor these patients' fluid intake throughout their hospital stay to ensure adequate hydration is maintained. This monitoring will allow for any difficulties the patient may experience to be identified and addressed in a timely manner. Although the finding that frailty may increase the risk for dehydration requires replication in larger prospective studies, it also suggests that hospital clinicians, including nursing staff, should maintain a high level of suspicion of dehydration in frail older patients and assess for its presence at admission to the hospital. Another unsurprising finding was that dehydration at admission significantly predicted dehydration at study exit, as de-fined by combined measures, and most likely reflects the unchanged status of one half of patients. This finding further underscores the importance of assessing and identifying any issues that frail older patients may experience regarding fluid intake and regularly monitoring their fluid intake while in the hospital.

Strengths and Limitations

Strengths of the current study include its prospective design and robust diagnostic approach for assessing dehydration. Comprehensive assessment of patients by experienced clinicians and collection of multiple measures of dehydration within 24 hours of admission to the hospital and again at study exit indicate data regarding patients' dehydration status are likely to be accurate.

Limitations of the study include its small sample, use of a convenience sample, and restriction of patient recruitment to the early part of the week, which means the sample may not be representative of all older patients admitted to an acute hospital. In addition, some data were missing due to patients being discharged without being followed up by research staff and, although this reflects the reality of conducting research in the hospital setting, it is a limitation. Lastly, hospital staff were informed of patients' dehydration status following clinical assessment and although this had the potential to influence patient treatment while in the hospital, the numbers of patients dehydrated at study exit suggests this was not the case.

Conclusion

Results of the current study show that the prevalence of dehydration among older, acutely unwell hospitalized patients is high, and that among cognitively intact patients, frail patients had higher rates of dehydration at admission compared to fit patients. This finding suggests frailty may be a risk factor for dehydration in these patients and highlights the importance of formally assessing older patients for dehydration at admission to the hospital and throughout their hospital stay.

References

  • Australian Institute of Health and Welfare. (2014). Australian hospital statistics 2012–13. Retrieved from http://www.aihw.gov.au/publication-detail/?id=60129546922
  • Brooker, C. (Ed.) (2008). Churchill Livingstone medical dictionary (16th ed.). London, UK: Royal Society of Medicine.
  • Chen, C.C., Dai, Y.T., Yen, C.J., Huang, G.H. & Wang, C. (2010). Shared risk factors for distinct geriatric syndromes in older Taiwanese inpatients. Nursing Research, 59, 340–347. doi:10.1097/NNR.0b013e3181eb31f6 [CrossRef]
  • Clegg, A., Young, J., Iliffe, S., Rikkert, M.O. & Rockwood, K. (2013). Frailty in elderly people. Lancet, 381, 752–762. doi:10.1016/S0140-6736(12)62167-9 [CrossRef]
  • El-Sharkawy, A.M., Sahota, O., Maughan, R.J. & Lobo, D.N. (2014). Hydration in the older hospital patient—Is it a problem?Age & Ageing, 43(Suppl. 1), i33–i35. doi:10.1093/ageing/afu046.1 [CrossRef]
  • Fortes, M.B., Owen, J.A., Raymond-Barker, P., Bishop, C., Elghenzai, S., Oliver, S.J. & Walsh, N.P. (2015). Is this elderly patient dehydrated? Diagnostic accuracy of hydration assessment using physical signs, urine, and saliva markers. Journal of the American Medical Directors Association, 16, 221–228. doi:10.1016/j.jamda.2014.09.012 [CrossRef]
  • Gladman, J.R., Porock, D., Griffiths, A., Clissett, P., Harwood, R.H., Knight, A. & Kearney, F. (2012). Care of older people with cognitive impairment in general hospitals. Retrieved from http://www.netscc.ac.uk/hsdr/files/project/SDO_FR_08-1809-227_V01.pdf
  • Glover, A., Bradshaw, L.E., Watson, N., Laithwaite, E., Goldberg, S.E., Whittamore, K.H. & Harwood, R.H. (2014). Diagnoses, problems and health-care interventions amongst older people with an unscheduled hospital admission who have concurrent mental health problems: A prevalence study. BMC Geriatrics, 14, 43. doi:10.1186/1471-2318-14-43 [CrossRef]
  • Hooper, L., Abdelhamid, A., Attreed, N.J., Campbell, W.W., Channell, A.M., Chassagne, P. & Hunter, P. (2015). Clinical symptoms, signs and tests for identification of impending and current water loss dehydration in older adults (1007). Cochrane Database of Systematic Reviews, 4, CD009647. doi:10.1002/14651858.CD009647.pub2 [CrossRef]
  • Inouye, S.K., Van Dyck, C.H., Alessi, C.A., Balkin, S., Siegal, A.P. & Horwitz, R.I. (1990). Clarifying confusion: The confusion assessment method: A new method for detection of delirium. Annals of Internal Medicine, 113, 941–948. doi:10.7326/0003-4819-113-12-941 [CrossRef]
  • Kumala, J., Nykänen, I., Mänty, M. & Hartikainen, S. (2014). Association between frailty and dementia: A population-based study. Gerontology, 60, 16–21. doi:10.1159/000353859 [CrossRef]
  • Mentes, J. (2006a). Oral hydration in older adults: Greater awareness is needed in preventing, recognizing, and treating dehydration. American Journal of Nursing, 106, 40. doi:10.1097/00000446-200606000-00023 [CrossRef]
  • Mentes, J. (2006b). A typology of oral hydration problems exhibited by nursing home residents. Journal of Gerontological Nursing, 23(1), 13–21. doi:10.3928/0098-9134-20060101-09 [CrossRef]
  • Mentes, J.C. & Kang, S. (2011). Hydration management. Iowa City, IA: University of Iowa.
  • Milte, R. & Crotty, M. (2014). Musculoskeletal health, frailty and functional decline. Best Practice & Research: Clinical Rheumatology, 28, 395–410. doi:10.1016/j.berh.2014.07.005 [CrossRef]
  • Pash, E., Parikh, N. & Hashemi, L. (2014). Economic burden associated with hospital postadmission dehydration. Journal of Parenteral and Enteral Nutrition, 38(Suppl. 2), 58S–64S. doi:10.1177/0148607114550316 [CrossRef]
  • Phelan, E.A., Borson, S., Grothaus, L., Balch, S. & Larson, E.B. (2012). Association between incident dementia and risk of hospitalization. Journal of the American Medical Association, 307, 165–172. doi:10.1001/jama.2011.1964 [CrossRef]
  • Rockwood, K., Song, X., MacKnight, C., Bergman, H., Hogan, D.B., McDowell, I. & Mitnitski, A. (2005). A global clinical measure of fitness and frailty in elderly people. Canadian Medical Association Journal, 173, 489–495. doi:10.1503/cmaj.050051 [CrossRef]
  • Storey, J.E., Rowland, J.T., Basic, D., Conforti, D.A. & Dickson, H.G. (2004). The Rowland universal dementia assessment scale (RUDAS): A multi-cultural cognitive assessment scale. International Psychogeriatrics, 16, 13–31. doi:10.1017/S1041610204000043 [CrossRef]
  • Thomas, D.R., Cote, T.R., Lawhorne, L., Levenson, S.A., Rubenstein, L.Z., Smith, D.A. & Morley, J.E. (2008). Understanding clinical dehydration and its treatment. Journal of the American Medical Directors Association, 9, 292–301. doi:10.1016/j.jamda.2008.03.006 [CrossRef]
  • Vivanti, A., Harvey, K., Ash, S. & Battistutta, D. (2008). Clinical assessment of dehydration in older people admitted to hospital: What are the strongest indicators?Archives of Gerontology and Geriatrics, 47, 340–355. doi:10.1016/j.archger.2007.08.016 [CrossRef]
  • Wei, L.A., Fearing, M.A., Sternberg, E.J. & Inouye, S.K. (2008). The confusion assessment method (CAM): A systematic review of current usage. Journal of the American Geriatrics Society, 56, 823–830. doi:10.1111/j.1532-5415.2008.01674.x [CrossRef]
  • Zuliani, G., Galvani, M., Sioulis, F., Bonetti, F., Prandini, S., Boari, B. & Gallerani, M. (2012). Discharge diagnosis and comorbidity profile in hospitalized older patients with dementia. International Journal of Geriatric Psychiatry, 27, 313–320. doi:10.1002/gps.2722 [CrossRef]

Characteristics of Participants With and Without Cognitive Impairment (CI) At Baseline (N = 44)

Characteristic With CI, n (%) Without CI, n (%) p Value
Gender
  Female 15 (55.6) 9 (52.9) 0.86
  Male 12 (44.4) 8 (47.1)
Age (years) (mean, SD) 80.24 (9.76) 81.63 (7.75) 0.6
Living situation
  Community-dwelling 25 (92.6) 16 (94.1) 0.85
  Residential aged care facility 2 (7.4) 1 (5.9)
Rowland Universal Dementia Assessment Scale
  Mean (SD) 15.12 (6.26) 25.59 (2.35) <0.001**
  Range 0 to 22 22 to 29a
Frailty status
  Well 5 (18.5) 3 (17.6) 0.2
  Managing well 2 (7.4) 4 (23.5)
  Vulnerable 2 (7.4) 1 (5.9)
  Mildly frail 4 (14.8) 6 (35.3)
  Moderately frail 11 (40.7) 2 (11.8)
  Severely frail 3 (11.1) 1 (5.9)
Frailty status (dichotomized)
  Frail 18 (66.7) 9 (52.9) 0.36
  Fit 9 (33.3) 8 (47.1)
No. of comorbid medical conditions
  Mean (SD) 2.26 (1.23) 1.41 (1) 0.03*
  Range 0 to 6 0 to 4
Body mass indexb
  <21 5 (18.5) 3 (17.6) 0.63
  22 to 27 13 (48.1) 6 (35.3)
  >27 9 (33.3) 8 (47.1)
No. taking psychotropic medications
  No 18 (66.7) 16 (94.1) 0.03*
  Yes 9 (33.3) 1 (5.9)
Dehydration risk appraisal checklist total scorec
  Mean (SD) 5.9 (2.9) 4.1 (2.7) 0.05*
  Range 1 to 13 0 to 9
Serum osmolality
  Normal 22 (81.5) 14 (82.4) 0.94
  295 to 300 mmol/L (impending dehydration) 3 (11.1) 2 (11.8)
  >300 mmol/L (potential dehydration) 2 (7.4) 1 (5.9)
Length of stay (days) (mean, SD) 5.15 (4.03) 4.06 (2.38) 0.32

Dehydration Status of Patients with and without Cognitive Impairment (CI), and with and without Frailty at Hospital Admission and Study Exit

Variable With CI (n = 27), n (%) Without CI (n = 17), n (%) χ2 (df) p Value
Admission 7 (25.9) 5 (29.4) 0.19 (1) 0.66
Study exit 5 (18.5) 4 (23.5) 0.05 (1) 0.83
Frail (n = 27), n (%)a Fit (n = 17), n (%)
Admission 8 (29.6) 4 (28.6) 0.01 (1) 0.94
Study exit 6 (27.3) 1 (9.1) 1.45 (1) 0.23

Keypoints

McCrow, J., Morton, M., Travers, C., Harvey, K. & Eeles, E. (2016). Associations Between Dehydration, Cognitive Impairment, and Frailty in Older Hospitalized Patients: An Exploratory Study. Journal of Gerontological Nursing, 42(5), 19–27.

  1. Dehydration is common among older hospitalized patients.

  2. Frailty may increase the risk for dehydration in cognitively intact older patients.

  3. Ongoing monitoring of older patients' hydration status should occur throughout hospitalization.

Authors

Dr. McCrow is Clinical Practice Development Facilitator, Churches of Christ Care in Queensland, Mitchelton; Ms. Morton is Senior Clinical Research Coordinator, Internal Medicine and Dementia Research Unit, Dr. Harvey is Clinical Director, Geriatric Medicine and Rehabilitation Internal Medicine Services, and Dr. Eeles is Consultant Physician in Geriatrics and Internal Medicine, The Prince Charles Hospital, Chermside, Queensland. Dr. McCrow is also Honorary Research Fellow, and Dr. Travers is Research Fellow, Dementia Collaborative Research Centre: Carers and Consumers, School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland. Dr. Harvey is also Senior Lecturer, and Dr. Eeles is also Senior Lecturer, School of Medicine, The University of Queensland, Brisbane, Queensland.

The authors have disclosed no potential conflicts of interest, financial or otherwise. The study was funded by the Dementia Collaborative Research Centres (DCRC), with ongoing support provided by Professor Beattie. The sponsor had no role in any aspect of the study, including its design, collection, analysis and interpretation of data, or in the writing of the report. The authors acknowledge Dr. Elaine Fielding, Senior Research Fellow at the DCRC, who provided valuable statistical advice for this manuscript; and research assistants, Mrs. Rosalee Trent, Ms. Althea Irwin, and Ms. Rachel McCrow.

Address correspondence to Catherine Travers, PhD, Research Fellow, Dementia Collaborative Research Centre: Carers and Consumers, School of Nursing, Queensland University of Technology, Level 6, N Block, Victoria Park Road, Kelvin Grove, Queensland 4059, Australia; e-mail: Catherine.travers@qut.edu.au.

Received: August 25, 2015
Accepted: January 06, 2016
Posted Online: February 05, 2016

10.3928/00989134-20160201-01

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