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Guideline Summary
Guideline Title
Dehydration and fluid maintenance in the long-term care setting.
Bibliographic Source(s)
American Medical Directors Association (AMDA). Dehydration and fluid maintenance in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2009. 29 p. [60 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Medical Directors Association (AMDA). Dehydration and fluid maintenance. Columbia (MD): American Medical Directors Association (AMDA); 2001. 28 p. [15 references]

Scope

Disease/Condition(s)
  • Dehydration
  • Fluid/electrolyte imbalance
Guideline Category
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Family Practice
Geriatrics
Internal Medicine
Nursing
Nutrition
Preventive Medicine
Speech-Language Pathology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Nurses
Pharmacists
Physician Assistants
Physicians
Social Workers
Speech-Language Pathologists
Guideline Objective(s)
  • To improve the quality of care delivered to patients in long-term care facilities
  • To guide the identification and management of dehydration and fluid/electrolyte imbalance in persons residing in long-term care settings
  • To present approaches that attempt to minimize the occurrence of dehydration and fluid/electrolyte imbalance
Target Population

Individuals residing in long-term care (LTC) facilities, including individuals who come to LTC facilities for short-term care

Interventions and Practices Considered

Screening/Diagnosis/Evaluation

  1. Evaluation of patients for risk factors and predisposing conditions for dehydration
  2. Consideration of medical history, body weight, physical examination, urine color, and intake and output measurement (Note: urine color is not a useful indicator of hydration status)
  3. Medical evaluation as indicated
    • Laboratory evaluation, including blood urea nitrogen (BUN), serum bicarbonate, creatinine, glucose, sodium, calcium, potassium
    • Measurement or calculation of serum osmolarity
  4. Identification of causes of and factors contributing to dehydration
  5. Classification of nature and severity of hydration status

Management/Treatment/Prevention

  1. Establishment of treatment goals
  2. Treatment based on clinical condition
    • Oral hydration
    • Subcutaneous fluid administration (hypodermoclysis)
    • Intravenous fluid replacement
  3. Provision of general support to patients, including treatment of comorbid conditions
  4. Monitoring of patients' response to interventions and subsequent adjustments of interventions as needed
  5. Establishment of a systematic approach to prevention and management of dehydration at the facility level
Major Outcomes Considered

Not stated

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Databases Searched: Medline, CINAHL, Cochrane, Ovid full text journals, PubMed

Time Frame: 2004--April 2009. Some pre-2004 articles were also included.

Inclusion Criteria: Persons 65 and over, human subjects, papers written in English, papers pertaining to all aspects of dehydration

Specific Terms Searched: Dehydration; hypo-hypernatremia; nursing homes; definition; diagnosis; lab testing and dehydration; glomerular filtration rate (GFR); blood urea nitrogen (BUN); serum osmolarity; hypodermoclysis; hypovolemia; hypervolemia; treatment; diagnosis; fluid-electrolyte imbalance; co-morbidities; antidiuretic hormone; hyperosmolar; physical signs of dehydration; orthostasis

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Original guidelines are developed by interdisciplinary workgroups, using a process that combines evidence- and consensus-based approaches. Workgroups include practitioners and others involved in patient care in long-term care facilities. Beginning with a general guideline developed by an agency, association, or organization such as the Agency for Healthcare Research and Quality (AHRQ), pertinent articles and information, and a draft outline, each group works to make a concise, usable guideline that is tailored to the long-term care setting. Because scientific research in the long-term care population is limited, many recommendations are based on the expert opinion of practitioners in the field. A bibliography is provided for individuals who desire more detailed information.

Guideline revisions are completed under the direction of the Clinical Practice Guideline Steering Committee. The committee incorporates information published in peer-reviewed journals after the original guidelines appeared as well as comments and recommendations not only from experts in the field addressed by the guideline but also from "hands-on" long-term care practitioners and staff.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

All American Medical Directors Association (AMDA) clinical practice guidelines undergo external review. The draft guideline is sent to approximately 175+ reviewers. These reviewers include AMDA physician members and independent physicians, specialists, and organizations that are knowledgeable of the guideline topic and the long-term care setting.

Recommendations

Major Recommendations

Note from the American Medical Directors Association (AMDA) and the National Guideline Clearinghouse (NGC): The original full-text guideline provides an algorithm on "Dehydration and Fluid Maintenance" to be used in conjunction with the written text. Refer to the "Guideline Availability" field for information on obtaining the algorithm, as well as the full text of the guideline, which provides additional details.

Recognition

Step 1

Does the patient have risk factors or predisposing conditions for dehydration?

Assess the patient for risk factors and other indicators that may predispose to dehydration (see Tables 1 and 2, below).

Table 1. Risk Factors for Dehydration
Altered thirst
  • Focal central nervous system lesions
  • Hypodipsia of aging
  • Medications (see Table 8 in the original guideline document)
Decreased cognitive function
  • Delirium
  • Dementia
  • Depression
  • Sedation
  • Psychosis/paranoia
Increased fluid losses
  • Diarrhea
  • Fever
  • Vomiting
  • Diuretics
  • Specialty air-flow mattresses
Limitations in oral intake
  • Dysphagia
  • Fear of urinary incontinence
  • Inadequate tube feeding volume
  • Limited mobility
  • Modified fluid consistency (thickened liquids)
  • Need for feeding assistance

 

Table 2. Potential Indicators Suggesting Increased Risk of or Need for Clinical Evaluation for Dehydration

Risk Factors

  • Acute illness
  • Decrease in fluid intake (<75% of food or fluid consumed at meals)
  • Dementia/depression
  • Dietary restrictions (e.g., thickened liquids)
  • Dysphagia
  • Excessive sweating, fever
  • Medications (e.g., angiotensin-converting enzyme [ACE] inhibitors, diuretics, laxatives, lithium, phenytoin toxicity)
  • Patient on nothing-by-mouth status (e.g., gastrointestinal preparation)
  • Vomiting/nausea/diarrhea/anorexia

Signs and Symptoms

  • Change in activities of daily living (ADLs)
  • Change in mental status
  • Constipation
  • Decreased urine output
  • Dizziness/faintness
  • Postural hypotension
  • Tachycardia
  • Weakness
  • Weight loss (3–5 lb in short time)

Step 2

Is the patient dehydrated?

Maintain a high level of suspicion for dehydration in the long-term care (LTC) setting.

  • Medical History
  • Body Weight
  • Physical Examination
  • Urine Color: Urine color is not a useful indicator of hydration status.
  • Intake and Output Measurement: Intake and output measurement should be relied upon sparingly because the value of such monitoring is limited in the LTC setting.

Assessment

The diagnosis of dehydration cannot be made on clinical grounds alone. Ultimately, the diagnosis is biochemical (established via laboratory tests). Because of potential complications, the diagnosis should be confirmed or excluded as quickly as possible.

Step 3

Is a medical workup appropriate?

Patients should be categorized according to their level of risk for dehydration or fluid/electrolyte imbalance and given a workup appropriate to their risk level.

Step 4

Perform appropriate laboratory evaluation.

If dehydration is suspected and a workup is indicated (or not limited by patient or family choice), at a minimum, obtain values for blood urea nitrogen (BUN), serum bicarbonate, creatinine, glucose, sodium, calcium, and potassium.

In addition, either directly measure or calculate serum osmolarity. This is a very sensitive measurement that rises in dehydration with a percentage body weight loss of as little as 1%. During dehydration caused by insufficient fluid intake, both plasma sodium and osmolarity are typically significantly elevated.

The BUN:Cr ratio should be used cautiously to assess hydration status.

Step 5

Determine the causes of and factors contributing to dehydration.

If the patient is dehydrated, it is important to try to identify the underlying causes of the dehydration. These efforts should be continued until a cause is identified or it is determined either that a cause cannot be identified or that identifying a cause would not change the treatment or ultimate outcome.

Step 6

Establish the severity of the patient's hydration status and summarize findings.

Using the information obtained in Steps 2 through 4, summarize the nature, severity, and causes of the patient's dehydration or risk for dehydration and assess the impact of this condition or risk on the patient's functioning and quality of life.

Treatment

Step 7

Establish treatment goals.

Treatment goals for the patient with dehydration may range from complete resolution of fluid/electrolyte imbalances to palliation.

Step 8

Address dehydration and manage related issues.

When treatment is indicated, the key to correcting dehydration is to correct water and sodium deficits. The choice of therapy depends on the patient's clinical condition, including complications that influence the type and urgency of rehydration efforts.

  • Subcutaneous Fluid Administration
  • Intravenous Fluid Replacement
  • General Support for Patients with Dehydration

Offer general support to all patients with dehydration. Such support may include administration of food and fluids, additional assistance as needed with activities of daily living (e.g., if dehydration has caused lethargy or delirium), and management of medical conditions that may be causing or complicating the patient's dehydration. The underlying cause or causes contributing to the dehydration should be identified.

Monitoring

Step 9

Monitor the patient's overall condition and responses to intervention.

Ongoing monitoring of patients' fluid/electrolyte status should include frequent checking for signs and symptoms that may indicate dehydration (see Steps 1 and 2). Closely monitor the patient's general status (e.g., level of consciousness, vital signs) as well as specific organ systems (e.g., heart, lungs, kidneys, skin) that can be affected by dehydration or by rehydration efforts. Also monitor the patient's emotional responses to treatment. The frequency of monitoring will depend on the severity of the fluid/electrolyte imbalance, the patient's physical and mental function, and the route and rate of rehydration.

Step 10

Improve the facility's approach to preventing and managing dehydration.

Prevention of Dehydration

Make reasonable efforts to try to prevent dehydration. A reasonable strategy is to combine individualized encouragement of fluids with efforts to address individual risk factors, to the extent possible, and individualized monitoring as indicated. The following strategies for preventing dehydration are based on expert consensus.

Strategies for Trying to Prevent Dehydration

  • Communicate clinical changes effectively
  • Emphasize the importance of hydration daily
  • Encourage family involvement in increasing fluid intake
  • Increase awareness of factors responsible for dehydration (e.g., fever, hot weather, diarrhea, vomiting)
  • Increase early identification of acute illness
  • Offer fluids regularly
  • Provide preferred beverages
  • Provide straws and cups that residents can use for drinking
  • Report promptly decreased fluid intake and possible signs or symptoms of dehydration
  • Try to manage urinary incontinence so that patients will be less likely to avoid fluids
  • Use a hydration cart
  • Use frozen juice bars
  • Use swallowing exercises and use cues before administering thickened liquids
Clinical Algorithm(s)

An algorithm is provided in the original guideline document for the recognition, assessment, treatment, and monitoring of dehydration.

Additionally, the appendices of the original guideline document contain the following algorithms:

  • Assessment and treatment algorithm for hyponatremia (Appendix 1)
  • Differentiating and treating loss of water vs. loss of water and sodium (Appendix 2)

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The guideline was developed by an interdisciplinary workgroup using a process that combined evidence- and consensus-based thinking.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

The following outcomes may be expected from implementation of this clinical practice guideline:

  • Appropriate hydration targeted to underlying causes
  • Earlier identification of fluid imbalances and their complications
  • Enhanced patient quality of life
  • Facilitation of patient-centered care goals
  • Greater individualization of care
  • Increased discussions with families about expectations, and the inability to prevent certain outcomes, in patients with dementia and dysphagia
  • Improved monitoring and treatment protocols
  • Improved staff education and awareness of this complex problem
  • More appropriate resource utilization
  • Reduction in potentially avoidable hospitalizations
  • Reduction in the number of inappropriate diagnoses of dehydration
  • Stable outcomes in cognition, falls, fatigue, function, and pressure ulcers and reductions in comorbid illnesses as a result of appropriate treatment of dehydration
Potential Harms
  • Hypodermoclysis can produce tissue slough or abscess formation at the site of administration. The risk of these adverse effects may be reduced by administering adjuvant recombinant human hyaluronidase to increase fluid absorption and dispersion. In rare cases, hypodermoclysis may result in overhydration.
  • Excessive free-water replacement or overly rapid rehydration can be harmful. Water intoxication (i.e., electrolyte imbalance, primarily severe hyponatremia, caused by excessive or overly rapid consumption or administration of hypotonic fluid) can cause dangerous or fatal disturbances of brain function. In addition, overly rapid rehydration can cause heart failure, especially in patients with impaired cardiac or renal function.

Contraindications

Contraindications

Contraindications to hypodermoclysis include:

  • Coagulation disorders or anticoagulant therapy
  • Severe hemodynamic instability (e.g., severe dehydration, shock)

Qualifying Statements

Qualifying Statements
  • This clinical practice guideline is provided for discussion and educational purposes only and should not be used or in any way relied upon without consultation with and supervision of a qualified physician based on the case history and medical condition of a particular patient. The American Medical Directors Association, its heirs, executors, administrators, successors, and assigns hereby disclaim any and all liability for damages of whatever kind resulting from the use, negligent or otherwise, of this clinical practice guideline.
  • The utilization of the American Medical Directors Association's Clinical Practice Guideline does not preclude compliance with State and Federal regulation as well as facility policies and procedures. They are not substitutes for the experience and judgment of clinicians and caregivers. The Clinical Practice Guidelines are not to be considered as standards of care but are developed to enhance the clinicians' ability to practice.

Implementation of the Guideline

Description of Implementation Strategy

The implementation of this clinical practice guideline (CPG) is outlined in four phases. Each phase presents a series of steps, which should be carried out in the process of implementing the practices presented in this guideline. Each phase is summarized below.

  1. Recognition
    • Define the area of improvement and determine if there is a CPG available for the defined area. Then evaluate the pertinence and feasibility of implementing the CPG.
  2. Assessment
    • Define the functions necessary for implementation and then educate and train staff. Assess and document performance and outcome indicators and then develop a system to measure outcomes.
  3. Implementation
    • Identify and document how each step of the CPG will be carried out and develop an implementation timetable.
    • Identify individual responsible for each step of the CPG.
    • Identify support systems that impact the direct care.
    • Educate and train appropriate individuals in specific CPG implementation and then implement the CPG.
  4. Monitoring
    • Evaluate performance based on relevant indicators and identify areas for improvement.
    • Evaluate the predefined performance measures and obtain and provide feedback.

Appendix 4 of the original guideline document provides a quality-improvement monitoring instrument that contains indicators for reviewing hydration status.

Implementation Tools
Chart Documentation/Checklists/Forms
Clinical Algorithm
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
End of Life Care
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
American Medical Directors Association (AMDA). Dehydration and fluid maintenance in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2009. 29 p. [60 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2001 (revised 2009)
Guideline Developer(s)
American Medical Directors Association - Professional Association
Guideline Developer Comment

Organizational participants included:

  • American Association of Homes and Services for the Aging
  • American College of Health Care Administrators
  • American Geriatrics Society
  • American Health Care Association
  • American Society of Consultant Pharmacists
  • Gerontological Advanced Practice Nurses Association
  • National Association of Directors of Nursing Administration in Long-Term Care
  • National Association of Health Care Assistants
Source(s) of Funding

Baxter Healthcare Corporation is a corporate supporter of this guideline.

Guideline Committee

Clinical Practice Steering Committee

Composition of Group That Authored the Guideline

Clinical Practice Committee Chair: Charles Cefalu, MD, MS

Project Chair: David Thomas, MD, CMD

Original Panel Members: *Jonathan Musher, MD, CMD, Chair; *Joseph Gruber, RpH, FASCP, CGP, Co-Chair; Linda Butterworth, GNP; Karenlee Graver-Potter, RN; Maryclaire Hassett, CCC-SLP; Annie More, RNC, MSN, GNP; Emma Najera, CAN; Ann Neal, PhD; Naushira Pandya, MD; Suzanne Rymer, RD, LD; Richard Stefanacci, DO, CMD; Andrew Weinberg, MD, FASCP, CMD

Contributors to Update: *David Thomas, MD, CMD, Chair; Steven Levenson, MD, CMD; Robin Arnicar, RN, CDONA/LTC; Cathleen Bergeron, RN, CDONA/LTC, MSHA; *Joseph Gruber, RPh, CGP, FASCP; Larry Lawhorne, MD, CMD; Barbara Resnick, PhD, CRNP; Laurence Rubenstein, MD, MPH; David A. Smith, MD, CMD; Eric Tangalos, MD, CMD

*Steering Committee Member

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Medical Directors Association (AMDA). Dehydration and fluid maintenance. Columbia (MD): American Medical Directors Association (AMDA); 2001. 28 p. [15 references]

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available from the American Medical Directors Association, 11000 Broken Land Parkway, Suite 400, Columbia, MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com External Web Site Policy

Availability of Companion Documents

A quality-improvement monitoring instrument containing indicators for reviewing hydration status is available in the appendices of the original guideline document.

Patient Resources

None available

NGC Status

This summary was completed by ECRI on December 3, 2002. The information was verified by the guideline developer on December 10, 2002. This summary was updated by ECRI Institute on July 20, 2010. The updated information was verified by the guideline developer on September 14, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is copyrighted by the American Medical Directors Association (AMDA). Written permission from AMDA must be obtained to duplicate or disseminate information from the original guideline. For more information, contact AMDA at (410) 740-9743.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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