Underhydration, the subclinical condition that leads to dehydration, is a persistent and complex issue for residents of long-term care. “I wish there was a test we could use [for underhydration] but there really isn't,” said Janet Mentes, Ph.D., R.N., of the University of California Los Angeles School of Nursing and author of numerous publications on hydration and the elderly. Keeping residents adequately hydrated requires consistent communication between nurses and certified nursing assistants (CNAs) and awareness on the part of all direct care staff. Early detection is crucial. There are definite connections between aging and hydration. Physiologically, older adults have a blunted thirst response. And secondary reasons for underhydration are often the consequences of additional health problems in older people, such as heart failure, renal disease, or cognitive impairment. For example, residents with dementia often are confused, and though they may be able to drink, they may not remember to do so. Dr. Neil Hall, director of the geriatric fellowship at the Mountain Area Health Education Center, Asheville, N.C., said the elderly cannot conserve water the same way younger persons can, “so they're at extra risk when they're in a particularly hot environment or are given diuretics; or when they're at the borderline dehydration stage. They can't conserve the water that they already have in volume.” Another problem is the difficulty of detecting underhydration, which simply means a patient isn't being given enough fluids. Once this happens, dehydration can occur rapidly, Dr. Mentes said. “I think that in a lot of nursing home residents, dehydration sometimes occurs very insidiously, so the staff doesn't pick up on it as easily,” she said. “What happens is that residents develop pneumonia or the flu and its consequences, and then they go to the hospital, and people say they have an infection when the enabling problem is that they weren't very well hydrated to begin with. I think it's a beginning of a long chain of issues.” In fact, between 1990 and 2000, hospitalizations of older adults for dehydration rose 40% (Clin. Nurs. Res. 2003;12:210–25). Dr. Mentes said some people are predisposed to the risk of dehydration because of their hydration habits, or profiles. Individuals with congestive heart failure or renal disease still need adequate amounts of fluid, despite any fluid restrictions. If a physician orders restricted fluids, “particularly if [the patient is] on dialysis or [has] renal problems, that is fairly overt.” Dr. Mentes said. “But there are lots of people in long-term care who have decreased renal function, and they're not on dialysis, so you have to be careful about overloading them; but you also don't want to pull back so that they're not getting enough fluid.” Dr. Mentes pointed out that when these particular residents get sick, “such as with a cold or pneumonia, and they don't eat for a couple of meals, they're really at risk for dehydration, because the window between being well hydrated, or even being adequately hydrated, and being dehydrated is very small.” When asked about the effect of understaffing on the monitoring of residents' fluid levels, Dr. Mentes shared a theory that she subscribes to. “Unfortunately, long-term care is very task focused and task oriented,” she said. “So the workers who are looking after 10 or 15 people tend to do those things that are most observable—such as grooming or bathing or [providing] clean clothes. Hydration in many ways is largely hidden.” Another related issue is that the staff often spends more time with the more frail people. “And that's probably appropriate.” Dr. Mentes said. “But a lot of the more intact folks are kind of left to fend for themselves.” Often when these residents get sick, nobody notices because the able ones generally feed themselves and drink independently. Dr. Mentes said she would especially encourage LTC staff to watch out for residents who can do more for themselves to make sure that if they don't eat a meal, someone finds out why. “In those circumstances, if the staff supplies them with extra fluids, they might be able to prevent that infection process, or at least cut down on the consequences of dehydration.” “If people do not get enough fluids, their behavior and well-being change dramatically,” said Linda Buettner, Ph.D., who is CTRS at the College of Health Professions, Florida Gulf Coast University, Fort Myers, Fla. (see sidebar). Dr. Mentes pointed out a practical matter concerning hydration. “You can certainly offer fluids to older people, but they may not want to drink them.” Incontinence is often a factor in such cases. When residents can't get themselves to the bathroom or can't get people to take them quickly, they don't want to drink much so they won't have to urinate. But in reality, the less fluid taken in, the greater the urge to urinate in some patients. In addition, when individuals restrict their own fluid intake in order to urinate less often, they may develop secondary problems such as urinary tract infections. The psychosocial aspects of incontinence also can factor into the equation. People feel ashamed when they lack control of their bodily functions, and it is particularly anxiety provoking for someone who is cognitively intact, Dr. Mentes said. A pitcher of water is an option when residents are immobile or just can't get to the faucet as easily as they can get to a pitcher. Pitchers need to be located near the bed so that they are within the resident's reach and staff need to make sure the pitchers contain enough water, but not so much that they are too heavy to lift. A pitcher is not an option for the resident who is unable to drink from a glass without assistance. Also, some drinks come wrapped up with caps on them, and residents often can't open them. In these cases, someone needs to come around on a regular basis and help the residents drink water. “And that takes time, and there's not enough time,” said Dr. Hall, “so it is a huge susceptibility issue.” Some professionals use a target to assess whether residents have been taking in enough liquid (B.R.N. 2006;7:197–203), but Dr. Hall said that the elderly resident's inability to conserve water adequately may make such tools less than efficient. Members of the long-term care team need to be reminded that monitoring and initiating hydration activities are important and shouldn't be neglected. This isespecially the case when an elderly individual returns to the long-term care facility after being hospitalized and treated for an acute medical condition such as pneumonia. The antecedent condition of underhydration or dehydration is often overlooked in these residents. Dr. Mentes said that thirst cannot be relied upon as a guide or predictor of dehydration. “Even when younger people wait until they get thirsty, they may be on the brink of dehydration.” “There's no question in my mind that the key to detecting dehydration” lies with the CNA,” said Dr. Hall, who is also medical director at Deerfield Episcopal Retirement Community in Asheville. “Most residents in LTC are at borderline hydration status at most times, and it doesn't take too much to tip them over to be truly hydrated.” Medications often factor into hydration issues, Dr. Hall further noted. For example, when a resident with congestive heart failure has been on furosemide (Lasix) for a long time and gets sick and stops drinking, continuing that person on a diuretic, particularly a loop diuretic, can precipitate more dehydration (Am. J. Cardiol. 2006;97:1759–64). This is a nursing issue, said Dr. Hall. He advises nurses to “call the doctor and ask, ‘Do you still want them on the diuretic, because they're not drinking.’” There are medicines that can perturb renal function in general, he said, and NSAIDs are probably the most significant ones. They tend to lead to overhydration, or at least to fluid retention, and ultimately, to dehydration. “This is also a cause of renal dysfunction, which can exacerbate the renal dysfunction that occurs with dehydration. So if their kidneys aren't working, there is probably not as much blood flowing to [their kidneys], because they're dehydrated, and if we also have to give them a nonsteroidal anti-inflammatory drug, which is toxic to the kidney, and especially in someone older than 75. It may cause significant kidney toxicity—more so than if they were well hydrated.” Another medication-related issue, according to Dr. Hall, is that dehydration can cause some medications to be more toxic. “Renally cleared drugs will not be cleared as easily, digoxin being one of them, which is almost completely cleared by the kidney.” In a study published in 2006, Dr. Mentes and her colleagues from UCLA demonstrated that a hydration management intervention could reduce episodes of infection and acute confusion when preceded by a state of underhydration, as measured by urine specific gravity and intake records. Although the results were not evaluated as statistically significant, there were clinically significant implications for nurses caring for elders in nursing homes. Despite being more physically frail, more cognitively impaired, and more at risk for acute confusion, the treatment group, which received the hydration management intervention based on a standard fluid goal, had 50% fewer hydration-linked events than did members of the control group (Clin. Nurs. Res. 2003;12:210–25). Dr. Mentes recommended that providers use at least a target for fluid goals. The standard that is based on weight is more convenient than those involving the use of body surface area, the foot-to-knee ratio, or other measurements (J. Am. Diet. Assoc. 1997;97:23–8). “For the first 10 kg, it's 100 mL of fluid, and then it's graduated down to 30 mL,” Dr. Mentes said. This includes fluid from all sources. One note about that standard is that [the minimum is] around 15 cc/kg per day, “which most [experts] would say is the lowest that you'd want to [strive] for in most” residents unless, again, “they have a food restriction or some other kind of problem,” Dr. Mentes said. For instance, Mary Ellen Posthauer, R.D., L.D., C.D., clinical vice president of Supreme Care West, Evansville, Ind. said, “people with severe cardiac or renal disease need fluids calculated at a lower level of 25 cc/kg of body weight rather than 30cc/kg of [body weight].” Rehydration can be done through a nasogastric tube in nursing facilities, said Dr. Hall, as long as the gut is working. This can potentially reduce hospitalizations. One area of hydration treatment that is getting renewed attention, he said, is that of hydroclysis (Am. Fam. Physician 2001;64:1575–8), which, although it is “old school,” it is much easier and safer than using intravenous fluids. “Subcutaneous infusions used to be done with long hypodermic needles, but the technology has changed,” he said. “If you can give a subcutaneous injection to a resident, you can do clysis.” Hydration carts and activities involving taste tests can be used to improve fluid intake. BY ANDREA M. SATTINGER From the Recreational Therapist's View Linda Buettner, Ph.D., CTRS, knows what she's talking about when it comes to hydration issues for the elderly. Besides teaching at Florida Gulf Coast University (Fort Myers), she also is the director of the university's Center for Positive Aging in Port Charlotte, Fla., which is located in the county with the highest population of elderly people in the nation. In such a hot climate, with so many older adults in her center's program, she is careful to train her staff about the importance of proper hydration. “My research has entailed using recreation therapy to help people with dementia have a better quality of life,” she said. When it comes to hydration issues, “We have all staff [including the recreation therapist, nurse practitioner, occupational therapist, physical therapist, and social worker] tuned in to look for symptoms like dry tongue, furrowed tongue, and very dry mucous membranes.” The program serves coffee and tea when participants arrive, and whenever there is a meal, residents can make their own fresh lemonade or sun-brewed tea. “This is an activity as well,” Dr. Buettner said. And since residents make the beverage themselves, “they all drink it … and it always taste[s] better [to them], and they're more trusting of it.” The program also holds events where they serve special foods. For instance, for the 4th of July, they had hot dogs and nonalcoholic beer. “People really love that,” she said. “These kinds of programs are social programs and not [based on] a medical model,” she said. By offering them, “we have the opportunity to help with oral hydration.” An important aspect of the hydration program is for the staff (and participating college students) to track and document fluid intake. Those patients with dementia get a particular prompt to start drinking. At the end of July, Dr. Buettner was working in a nursing home in New York City. “We were working very closely with CNAs and the activities department, so that they could mesh the personal care issues with what was going on in the activities…. All of that is really important in terms of quality of life for people. I think the more interdisciplinary we are in our approach, the better off our clients and residents are going to be.” Because they work so closely with family caregivers, the staff is better able to track hydration issues. “One of our caregivers came in and said her husband had become very violent” in the last “day or so,” and she wanted to know what she should do. This man was moderately impaired with dementia, and also was big and strong and was living with his wife at home. “We recognized immediately that the gentleman was dehydrated,” Dr. Buettner said. In addition to dementia, “he had delirium due to dehydration…. As soon as his hydration was improved, all those behavior problems disappeared.” The Registered Dietitian's View Many LTC facilities “push to get that [CMS-regulated] 1,500 cc per day for older adults onto their [meal] trays,” said Mary Ellen Posthauer, who for 20 years was the CEO of a dietary consulting business in Evansville, Ind. “The problem with that is if you get all that liquid on their trays, it's overwhelming [to residents]. The coffee, the juice, milk…. The food is overwhelming as it is, but then when they see all these liquids, they can't possibly drink all that and eat the food. We train the CNAs that when they're assisting someone to eat, they need to intersperse the food with sips of fluid.” In addition, dysphagia is a widespread problem and it is a major challenge to get residents to drink the thickened [nutritional] liquids. Many of them do not like the taste,” or the texture. “We try to get beverages that they enjoy.” And “we usually talk to the families because they often do not understand the benefits of [hydration]. Sometimes they get to a point where the quality of life is more important to them than, for instance, the high risk of aspiration. So they choose to let them [residents] take that risk in order to drink their coffee, or drink their soft drink that they enjoy versus becoming dehydrated because they won't drink it.” Straws can be a safety risk for some residents because they may aspirate. The facility's speech therapists will make the recommendations and those are usually printed on the cards that go out with [meal] trays. If a resident uses a straw, “they may tend to gulp the fluid down and then [it] rushes right to their lungs. This often goes along with the dysphagia,” Ms. Posthauer noted. Aside from coffee and tea, any of these fluids also have calories as well as protein, vitamins, and minerals. We encourage [the use of] nutritional supplements, but [only] between meals. Otherwise, “they fill up on that and don't eat the food. The supplement might have 200 calories, but the meal has 600 calories. Also, some high-protein supplements are dehydrating, so residents need to have fluid with those. “I have used hydration carts that circulate once or twice a day. It's helpful even if you're giving them 4 ounces of something to drink, because they'll take it if it is offered to them. And many times they'll accept lemonade or juice a lot better than they do water…. [It is often said] that people in nursing homes don't have choices, and this sounds like a simple choice, but it can mean a lot to them.” The following is a list of the many ways recreational therapists have found to promote good hydration: ▸ Provide a water cooler in the program area for self-access. ▸ Help residents who are immobile to access the water cooler. ▸ Give reminders (provide a prompt) to initiate getting a drink. ▸ Use water bottles with sippers (flexible straws) during exercise classes or wheelchair biking. ▸ Include enticing drinks (root beer floats, lemonade, smoothies) as desserts in therapeutic cooking programs. ▸ Offer fluids every 1.5 hours, and offer assistance to the bathrooms each time. ▸ Include fluids in cognitive-based programs, such as having residents taste different fluids (grape juice, milk, lemonade, iced tea) and guess what they are. ▸ Use special events to highlight special treats to drink (nonalcoholic beer or wine and other virgin drinks). ▸ Monitor and note each participant's ability or desire to drink during the recreational programs. ▸ Monitor and note dry mucous membranes and furrowed tongues at the start and finish of programs. ▸ Monitor and investigate changes in behavior, for better or worse, that may indicate possible dehydration. ▸ Offer fluid-dense foods such as gelatin, soups, juices, shakes, fruit juice bars, sherbet, melon, and berries.