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Detecting dehydration & malnutrition in the elderly

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    Detecting dehydration & malnutrition in the elderly

    by Hamilton, Sandy

    <!-- google_ad_section_start -->By recognizing a potential problem early, you may save an elder adult from a debilitating complication. Here's what you need to know.
    WHETHER YOU WORK in a hospital, long-term care, or home health care, you've undoubtedly encountered an elderly patient who's dehydrated or malnourished. Confusion and disorientation, which aren't normal at any age, may have been your first clues.

    Because dehydration and malnutrition can have such serious consequences in older patients, make early recognition and treatment a priority. Use the following information and guidelines to assess for problems and intervene appropriately.

    Why dehydration threatens

    <!-- END WIDGET: FA POPULAR RESULTS -->Physiologic changes related to aging make an elderly adult especially prone to dehydration. She has about 10% less body fluid than a younger adult, so she has less fluid reserve to start with. Because her sense of taste diminishes with age, food may become unappetizing. Consequently, she may eat less and use more salt, raising her body's need for water. At the same time, however, her thirst response can diminish, so she may not recognize the need to drink more. For these reasons, an elderly adult may become severely dehydrated very quickly, before she feels thirsty or anyone notices symptoms.

    Fever can contribute to dehydration. Because an elderly adult's normal body temperature may be lower than 98.6deg F (37deg C), a temperature increase may be undetected at first. Always check the patient's temperature against her baseline. A temperature of 98deg F (36.7deg C) is a lowgrade fever for someone whose temperature is normally 97deg F (36.1deg C). Generally, 1 degree of fever increases total body water needs by 10%.

    A fever can be a consequence of dehydration as well as a cause: A low-grade fever develops if the patient doesn't have enough fluid to adequately cool her body. The result is a downward spiral of dehydration and increasing body temperature, further raising fluid needs and compounding dehydration.
    Signs and symptoms of dehydration include irritability, confusion, tachycardia, low urine output, dry skin, constipation, fecal impaction, dizziness, hypotension, infection, bowel blockage, and skin breakdown. If allowed to continue unchecked, dehydration may lead to falls, stroke, renal failure, and death.

    You can classify patients at highest risk for dehydration into groups based on underlying cause:

    * mechanical impairments, such as mechanical ventilation, which prevent patients from drinking
    * functional impairments, such as coma or paralysis. Also at risk are patients who are kept N.PO. for tests, especially if the tests are rescheduled several times.
    * physiologic factors, such as medications that increase fluid loss (diuretics and laxatives) or that inhibit the thirst response or another mechanism that helps maintain fluid balance. Some enteral and total parenteral nutrition alter the fluid balance of the intracellular and intravascular spaces. Draining wounds or fistulas also increase fluid output, raising the patient's risk of dehydration.
    * psychological factors, such as depression, which can cause a loss of appetite and fluid intake. Elderly patients also may purposefully decrease their fluid intake to eliminate frequent trips to the bathroom or to control incontinence.

    Looking for problems
    Whenever you assess an elderly patient, look for the following signs of dehydration:

    * poor skin turgor on the forehead or sternum-not the hand or arm. Because of skin changes that occur with aging, skin turgor on the arm is an unreliable indicator of dehydration.
    * sunken eyes
    * dry mucous membranes
    * irritability
    * confusion
    * dizziness
    * muscle weakness
    * acute weight loss of 2 or more pounds (0.9 kg); 2.2 pounds (1 kg) equals about 1 liter of fluid over a few days
    * decreased urine output
    * increased heart rate
    * orthostatic hypotension
    * fever
    * unexplained elevations in key lab studies, such as urine specific gravity, blood urea nitrogen, electrolytes, or hemoglobin values.

    Monitor fluid intake and output, weigh the patient daily, and watch for ominous trends: decreasing intake, increasing output, changes in lab results, and changes in emotional or mental status. If you suspect dehydration, review her care plan for anything that may be contributing to a fluid imbalance, such as N.P.O. status, fluid restrictions, or diuretic use.When, for whatever reason, a patient can't reach for and hold a glass of water, include ways to encourage fluid intake in the care plan. For example, set up a schedule for offering fluids.

    Know your patient's medications and their potential for adverse effects and interactions. Be alert to medications, such as diuretics, that can lead to dehydration. Your pharmacist can help you with this task.
    Finally, educate staff, patients, and family members on the causes and symptoms of dehydration, what signs and symptoms to watch for, and how to avoid problems.

    Spotting malnutrition

    Even if she's eating regularly, an elderly patient is also at higher risk for malnutrition because of physiologic changes of aging. Nearly 30% of people over age 65 have a diminished ability to produce stomach acid, which impairs absorption of many important nutrients, such as folic acid, vitamin B12, iron, and calcium. A diminished sense of taste and smell make food less appetizing, and dental problems can make chewing difficult.

    As the elderly patient loses weight, she also loses muscle mass and strength, becoming more frail. Her immune system may become impaired, opening the door for disease. Continued illness can lead to depression, causing loss of appetite and further weight loss. Besides hampering the body's ability to heal, reduced serum albumin levels decrease the number of binding sites available to protein-binding medications. This puts the patient at risk for toxic reactions to relatively low doses of some medications.
    Some of the signs of malnutrition, such as disorientation, are erroneously considered normal signs of aging, so consider the degree and the number of signs you see. The more signs the patient has and the more rapidly they developed, the higher the probability that she's malnourished. For signs and symptoms, see Malnutrition's Clues.

    Albumin and prealbumin levels can help identify the presence and severity of malnutrition. If the patient is also dehydrated, these values may appear elevated. Once she's hydrated, however, plasma protein levels are usually low, as are hemoglobin and hematocrit. Don't be fooled by normal hemoglobin and hematocrit levels if serum osmolality indicates a fluid deficit. These values will fall once she's hydrated.

    Lack of vitamin A, though rare, can impair the patient's sense of taste and smell. Combined with the natural decline in the sense of taste in the elderly, this could make food taste like sawdust.

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    If your patient is malnourished, obtain a dietary consult and enlist the help of the entire care team. Along with serum albumin and prealbumin levels, obtain a calorie count to determine the patient's calorie intake and help plan dietary interventions. If indicated, have a speech therapist evaluate her ability to swallow and her aspiration risk.

    Frequent, small meals throughout the day may be more appealing to the patient than three larger ones. Also offer liquid supplements between meals.
    If the patient can't eat enough to correct malnutrition, she may require enteral feedings. Explain your concerns to the patient and her family; if she's alert, she'll need to consent to enteral tube insertion and feedings. If she can eat, schedule tube feedings at night and encourage her to eat meals during the day.

    Meeting the threat

    Dehydration and malnutrition threaten your most vulnerable elderly patients. Protect them from debilitating complications by assessing for problems and intervening at the first sign of trouble.

    Malnutrition's class
    Assess for these signs of malnutrition:
    * an emaciated appearance or being underweight (defined as 15% to 20% below ideal body weight)
    * muscle wasting or loss of subcutaneous fat
    * poor coordination
    * muscle weakness fatigue
    * dry, brittle, or thinning hair or hair loss
    * dry skin with poor coloring
    * patchy dermatosis
    * dry, cracked lips
    * swollen red tongue (glossitis)
    * reddened, swollen, or receding gums
    * poor wound healing
    * reduced resistance to infection.

    Gants, R.: "Detection and Correction of Underweight Problems in Nursing Home Residents," Journal of Gerontological Nursing. 23(12):26-31, December 1997.
    Last edited by AlaskaDenise; November 21, 2007, 04:13 AM. Reason: remove advertisement

  • #2
    Good dehydration info everyone should know..
    ?The only security we have is our ability to adapt."