The evidence grade rating scheme (A-D) is provided at the end of the "Major Recommendations" field.
The following screening criteria indicate patients who are likely to benefit the most from use of this protocol:
- All individuals >85 years of age
- All institutionalized elders
- Individuals with recent weight loss ≥5% of body weight
- Individuals with feeding/eating difficulties
- Individuals with a diagnosis of dementia
- Individuals with congestive heart failure
- Febrile individuals
Essential Areas for Assessment of Hydration Status in the Elderly
(See Appendix A.1 in the original guideline document for an example of an assessment form that can be used.) Several areas are essential to assess with regard to the hydration status of elders. These include a health history, physical assessment, laboratory tests, functional assessment and individual fluid intake behaviors.
Health history may be obtained through interview or by reviewing the patient's record. It should include (EG = C1):
- Specific disease states: dementia, congestive heart failure, chronic renal disease, malnutrition, and psychiatric disorders such as depression, schizophrenia, and bipolar disorder.
- Presence of co-morbidities: >4 chronic health conditions
- Prescription drugs: number and types
- Past history of: dehydration, overhydration, repeated infections
Components of physical assessments that are essential to include are (EG = C1):
- Vital signs
- Body mass index (BMI) which can be calculated from height and weight with the following formula: weight in kg. divided by height in m2. BMI <21 or >27 puts an individual at risk (EG = D). Recent evidence suggests that a lower BMI confers risk (EG=C1).
- Review of Systems or Head to Toe Assessment--Make sure to include an assessment of the oral cavity, upper body strength and speech (EG = C1).
- Additional signs of hydration status and the relative strength of each in assessing dehydration are in Table 1 in the original guideline document.
Many laboratory tests can be helpful in assessing hydration status in the elderly (see Table 2 in the original guideline document). It should be noted that the blood tests are better predictors of actual dehydration and the urine tests are better at predicting impending dehydration or those patients at risk for developing dehydration and it is important to obtain a baseline value for comparison and evaluation of significant changes (EG = B2; EG = D; EG = C1). Saliva analysis for osmolality has been explored and appears promising although no normative values have been established (EG = B2). Bioelectrical Impedance Analysis has been used to estimate total body water in research studies (EG = C1).
Cognitive impairments, functional dependence and depression have all been identified as risk factors for dehydration in the elderly, therefore the following assessments are recommended:
- Cognitive screening (one of the following): Mini Mental State Exam (MMSE), Short Orientation Memory Test, Short Portable Mental Status Questionnaire (SPMSQ), Minimum Data Set (MDS) Cognitive Performance Scale
- Activities of daily living (ADLs) (one of the following): Katz ADLs, Functional Independence Measure (FIM), ADL section from Resident Assessment Instrument of MDS, Barthel Index
- Mood (one of the following): Geriatric Depression Scale (GDS), Beck Depression Scale, Cornell Scale for Depression in Dementia
Individual Fluid Intake Behaviors
An individual's fluid intake behavior is important to assess. When assessing the individual's usual fluid intake pattern ask the following:
- Do they consume most of their fluids during meals?
- At what time of the day do they consume the most fluids?
- What is the actual amount of fluid intake?
- What types of fluids are preferred?
Assess any problematic behaviors associated with fluid intake. These include choking, drooling, spilling, visual impairment, inability to hold a cup independently, or resistance to drinking due to fear of incontinence (EG = C1).
Description of Intervention
The hydration management intervention is an individualized daily plan to promote adequate hydration based on risk factor identification that is based on a comprehensive assessment. The intervention is divided into three phases:
- Risk identification phase
- Hydration management phase
- Evaluation phase
Based on the assessment data, a risk appraisal for hydration problems is completed using the Dehydration Risk Appraisal Checklist revised by Mentes & Wang (EG = C1). The more of the following risk indicators that are present, the greater the likelihood of dehydration: Specifically, history of dehydration and difficulty swallowing were risk factors for dehydration (EG = C1) (see the "Dehydration Risk Appraisal Checklist" in the original guideline document).
Another way to conceptualize risk for dehydration is to classify oral hydration habits.
See Figure 1 in the original guideline document details the different strategic measures according to the residents' drinking habits (EG = C1). The tailored guide can be helpful in maximizing hydration for each individual patient.
Managing fluid intake for optimal fluid balance consists of 1) acute management of oral intake and 2) ongoing management of oral intake.
Acute Management of Oral Intake
Any resident who develops a fever, vomiting, diarrhea or a non-febrile infection should be closely monitored by implementing intake and output records and provision of additional fluids as tolerated (EG = C1). Individuals who are required to be NPO (nothing by mouth) for diagnostic tests should be given special consideration to shorten the time that they must be NPO and should be provided with adequate amounts of fluids and food when they have completed their tests. For many procedures a 2 hour fluid fast is recommended (EG = B1).
Any resident who develops unexplained weight gain, pedal edema, neck vein distension or shortness of breath should be closely monitored for overhydration. Fluids should be temporarily restricted, and the resident’s primary care provider will be notified.
Ongoing Management of Oral Intake
Ongoing management of oral intake consists of the following five components:
- Calculate a daily fluid goal
All residents need to have an individualized fluid goal determined by a documented standard for daily fluid intake. There is evidence that the standard suggested of 100mL/kg for first 10kg of weight, 50 ml/kg for next 10kg, and 15mL for remaining kg or 75% of 1600 ml per m2 of body surface/day is preferred.
- Since this standard reflects fluid from all sources, to calculate a standard for fluids alone, 75% of the total calculated from the formula can be used. Other standards include:
- 1600ml per m2 of body surface/day (or more recently 75% of this standard) (EG = C1)
- 30mL/kg body weight with 1500mL/day minimum (EG = D)
- 1mL/kcal fluid for adults (EG = D)
- No less than 1600 ml/24 hours (EG = A1)
- Compare resident's current intake to the amount calculated from applying the standard.
- Provide fluids consistently throughout the day (EG = A1).
- Plan fluid intake as follows: 75%-80% delivered at meals, and 20%-25% delivered during non-meal times such as medication times and planned nourishment times (EG = D).
- Offer a variety of fluids keeping in mind the individual's previous intake pattern (EG = C1; EG = D). Alcoholic beverages which exert a diuretic effect on the resident should not be counted toward the fluid goal. Caffeinated beverages may be counted toward the fluid goal based on individual assessment, as there is preliminary evidence that in individuals who are regular users there are no untoward effects on fluid balance (see Appendix B in the original guideline document for Comparisons of Common Oral Fluids) (EG = A1; EG = C1).
- Fluid with medication administrations should be standardized to a prescribed amount (e.g., 180mL [6oz.] per administration time) (EG = B2).
- Plan for at risk individuals
For residents who are at risk of underhydration because of poor intake, the following strategies can be implemented based on unit preference, time, and staffing issues:
- Fluid rounds mid-morning and late afternoon, where caregiver provides additional fluids (EG = B2).
- Provide 2-8 oz. glasses of fluid in AM and PM (EG = B2).
- "Happy Hours" in the afternoon, where residents can gather together for additional fluids and socialization (EG = C1)
- "Tea Time" in the afternoon, where residents come together for fluids, nourishment and socialization (EG = D)
- Use of modified fluid containers based on resident's intake behaviors (e.g., ability to hold cup, to swallow) (EG = D)
- Offer a variety of fluids and encourage ongoing intake throughout the day for cognitively impaired residents. Offer fluids that residents prefer (EG = C1)
- Offering encouragement to drink (EG = C1)
- Encourage family involvement and support (EG = C1).
- Coordinate staff communication about hydration such as certified nursing assistant (CNA) handoff reports or documentation in nursing care plan. (EG = C1)
- Fluid regulation and documentation
- Individuals who are cognitively intact and visually capable can be taught how to regulate their intake through the use of a color chart (see Appendix A.3 in the original guideline document for description), to compare to the color of their urine. For those individuals who are cognitively impaired, caregivers can be taught how to use the color chart. The chart is most accurate in individuals with better renal function (EG = B2; EG = C1).
- Frequency of documentation of fluid intake will vary from setting to setting and is dependent on an individual's condition. However, in most settings at least one accurate intake and output recording should be documented and should include the amount of fluid consumed, intake pattern, difficulties with consumption, and a urine specific gravity and color (see Appendix A.4 in the original guideline document).
- Accurate calculation of intake requires knowledge of the volumes of containers used to serve fluids. This should be posted in a prominent place on the care unit as a study suggested that nurses over- or under-estimated the volumes of common vessels. (EG = C1)
Adherence to the hydration management guideline can be monitored by (frequency of monitoring to be determined by setting):
- Urine specific gravity checks, preferably a morning specimen (EG = C1; EG= A1)
- A value greater than or equal to 1.020 implies an underhydrated state and requires further monitoring (EG = B2; EG = C1)
- Urine color chart monitoring, preferably a morning specimen (EG = C1)
- 24 hour intake recording (output recording may be added, however in settings where individuals are incontinent of urine, an intake recording should suffice) (see Appendix A.4 in the original guideline document) (EG = A1)
Deviations from the guideline should be discussed with the individual's primary nurse and updated plans to manage hydration status will be implemented.
Rating Scheme for Strength of Evidence
A1 = Evidence from well-designed meta-analysis or well done systematic review with results that consistently support a specific action (e.g., assessment, intervention, or treatment)
A2 = Evidence from one or more randomized controlled trials with consistent results
B1 = Evidence from a high quality evidence-based practice guideline
B2 = Evidence from one or more quasi-experimental studies with consistent results
C1 = Evidence from observational studies with consistent results (e.g., correlational descriptive studies)
C2 = Inconsistent evidence from observational studies or controlled trials
D = Evidence from expert opinion, multiple case reports, or national consensus reports