Dehydration in medical practice, which is different from its general meaning, refers to the body losing water at a faster rate than it can replace it, with or without salt. We believe that the medical definition of dehydration, which involves the overall loss of body water, is the most effective for addressing patients' medical needs. There are two types of dehydration: water loss dehydration (hyperosmolar), which can be caused by increased sodium or glucose, and salt and water loss dehydration (hyponatremia). Diagnosing dehydration requires evaluating the patient's condition, conducting laboratory tests, assessing their symptoms, and understanding their medical history. Long-term care facilities are hesitant to diagnose dehydration, partly because it is seen as an indicator of poor care. These facilities should focus on educating their staff from different disciplines about preventing dehydration, considering the negative outcomes associated with its occurrence. We also argue that dehydration is rarely a result of neglect by formal or informal caregivers, but rather stems from a combination of physiological factors and diseases. With the availability of recombinant hyaluronidase, subcutaneous infusion of fluids (hypodermoclysis) offers a better option for treating mild to moderate dehydration in nursing homes and at home.
Water Regulation in the Body
Water is essential for the proper functioning of our bodies, constituting approximately 55% to 65% of our body weight. The majority of water is contained within our cells, while the remaining percentage is found outside the cells. A small portion, around 25% of the extracellular water, is present in our blood vessels. As we age, the overall water content in our bodies, encompassing both intracellular and extracellular water, decreases.
Throughout medical history, two types of fluid loss have been recognized: volume depletion, which refers to the loss of fluid affecting the blood arteries and interstitial spaces, and dehydration, which pertains to the loss of water from within the cells.
Epidemiology.
In research about dehydration, there are challenges in accurately diagnosing it and inconsistent methods used in studies. In a study conducted by Miller and colleagues, they focused on older African Americans (with an average age of 79.7 years) living in the community. They discovered that 10% of the participants had a higher BUN/creatinine ratio, indicating potential dehydration, while only 1% had elevated sodium levels. They also found that individuals who were depressed or had impaired functioning were at a higher risk of dehydration. The study showed that dehydrated individuals performed poorly on timed tests and had difficulty standing on one leg.
Delirium,
There's a new idea that checking a person's mental state should be considered as important as checking other vital signs like heart rate and blood pressure. It's widely known that dehydration often leads to a condition called delirium, which causes confusion and disorientation. In nursing homes, residents who show signs of agitation or aggression are more likely to have problems with appetite, weight loss, and dehydration. Dehydration and infections are common reasons for sudden confusion in nursing home residents.Experts have suggested a general pattern of how dehydration affects behavior, starting from mild to severe stages.
Identifying Dehydration:
It can be challenging to accurately identify dehydration based on clinical symptoms and signs alone. They are not very sensitive or specific indicators of dehydration, so it's important to be highly suspicious when making a diagnosis. In a nursing home setting, Chassagne and colleagues found that factors like orthostasis (feeling dizzy when standing up), decreased skin elasticity (especially in the subclavian and forearm areas), rapid heartbeat, dry mouth, and changes in consciousness (such as delirium) were associated with dehydration. However, none of these factors alone can definitively confirm dehydration. Skin elasticity, in particular, is not always reliable due to the loss of subcutaneous fat.
Management of Dehydration:
Recognizing the challenges in diagnosing dehydration, the fact that it is often caused by underlying diseases or excessive urination, and its potential for rapid development, it is crucial for healthcare facilities to maintain a proactive approach to fluid management. This involves increasing the involvement of certified nursing assistants in assessing the risk of dehydration and making it a part of the daily nursing checklist. Healthcare providers need to be more aware of the risk factors for dehydration, such as fever, exposure to hot environments, and limited access to fluids, and take appropriate measures to prevent dehydration.
Subcutaneous infusion, also known as hypodermoclysis, is a method used to provide fluids to people who have mild to moderate dehydration. It has become popular again for hydrating individuals in nursing homes and at home.
People who show signs of mild to moderate dehydration are suitable candidates for subcutaneous infusion. However, it is not appropriate for individuals with severe dehydration that requires hospitalization, those experiencing or at risk of shock or low blood pressure, those who need medication administered through a vein, those with severe heart failure, or those with acute conditions.
In summary, dehydration is common in older people and can have negative effects on their health and quality of life, including an increased risk of death. Dehydration occurs due to a combination of natural aging processes and various health conditions. It is important to note that dehydration in older people is usually not caused by neglect. Older individuals may not always recognize the need to drink more fluids to compensate for fluid loss, putting them at higher risk of dehydration even when fluids are availab
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