Dehydration in Elderly Patients

• These are study notes about care for the older adult focusing on dehydration, failure to thrive, and palliative care/end-of-life care, according to NURS 6121.

Dehydration

• Dehydration is more prevalent in older adults.
• Fluid intake deprivation or excessive fluid loss defines dehydration.
• Sodium imbalance is the most significant electrolyte abnormality.

Types of Dehydration

• Isotonic dehydration involves a balanced loss of sodium and water, potentially from vomiting or diarrhea.
• Hypertonic dehydration involves excessive water loss from renal disease or osmotic diuresis.
• Hypotonic dehydration involves excessive sodium loss, possibly from diuretics.

Intake Issue Risk Factors

• Environmental factors
• Restricted ambulation
• Increased metabolic demands
• Infections
• Pharmacologic Factors, narcotics and sedatives
• Normal aging changes
• Poor appetite
• Fluid limitations
• Prevent urinary incontinence
• Management of heart failure

Output Issue Risk Factors

• Environmental Factors
• Hot weather
• Increased metabolic demands
• Infections, diarrhea
• Endocrine disorders
• Diabetes insipidus
• Hyperglycemia
• Pharmacologic Factors
• Normal aging changes

Clinical Presentation of Dehydration

• Confusion
• Lethargy
• Rapid weight loss
• Functional decline

Important Assessment Data Relevant to Dehydration

• Fluid intake status
• Functional status
• Weight
• Cognition
• Bowel habit (constipation, diarrhea)
• Medications

Physical Signs of Dehydration

• Cardiovascular assessment may reveal a drop in blood pressure and a rise in pulse.
• Temperature may be elevated with dehydration
• Concentrated urine
• Dry tongue and mucous membrane
• Poor skin turgor is unreliable in older adults due to changes in skin collagen.

Relevant Diagnostics

• Serum electrolytes; sodium greater than 148 mEq/L or hyponatremia
• BUN/creatinine ratio greater than 25:1 suggests dehydration
• Osmolality
• H&H
• Glucose concentration

Dehydration Management

• Orthostatic hypotension
• Delirium
• UTI

Potential Interventions

• Oral hydration; more than 1600 mL per 24 hours
• IV or hypodermoclysis replacement
• Hospitalization if the patient is unstable with altered mental status.

Dehydration Prevention

• Drink six to eight 8 oz glasses of water or juice daily.
• Daily take a full glass of liquids with medications
• Drink more than usual in hot weather or when experiencing a fever.
• Keep a fluid intake record for 2 days.
• Address dental hygiene, mental health, or poorly fitting dentures in relation to food and fluid intake.
• Individuals with memory problems need fluid monitoring.

Failure to Thrive (Frailty)

• Progressive loss of energy, strength, and stamina lead to decreased function and general cognitive deterioration.
• It is strongly correlated with age, especially the late stages of decline.
• Results in decreased strength and endurance, weakness, and fatigue.
• Not synonymous with comorbidity or disability.

Hallmark Symptoms of Geriatric Failure to Thrive

• Impaired physical function
• Malmutrition
• Depression
• Cognitive Impairment

Potential Causes

• Diseases, such as organ failure, metastases, infection, stroke, thyroid disease, and fractures.
• Medications can cause it, especially cognitive changes, anorexia, and dehydration.
• Environmental causes include isolation, neglect, and poverty.
• Psychiatric causes such as depression, dementia, psychosis, and delirium.
• Gastrointestinal causes include malabsorption, dysphagia, dental problems, diarrhea, and vitamin deficiency.

Relevant Health History

• Signs of organ failure
• GI malabsorption
• Cancer risk factors
• Infection
• Thyroid abnormalities
• Depression
• Changes in memory

Clinical Presentations

• Weakness
• Inability to care for self
• Dizziness
• Weight and memory loss
• Depression

Diagnosis

• Diagnosis of a clinical syndrome requires 3 or more of the following:
• Unintentional weight loss (10 lbs in the past year)
• Exhaustion/fatigue
• Weakness
• Slow walking speed
• Low physical activity

Relevant tests to consider:

• Complete physical exam; may have no gross abnormality
• Tests to consider, CBC, electrolytes, kidney, and thyroid studies, fasting blood glucose, and liver function tests

Interventions to Consider

• Adequate protein and caloric intake (nutrition consult)
• Megestrol acetate (Megace)
• Vitamin D supplement 800 IU
• Regular exercise (PT consult)
• Family education and support measures

Palliative Care

• Specialized medical care for people with serious conditions.
• Focuses on relief of symptoms, physical, psychosocial, and spiritual dimensions, distinct from hospice care.
• Patient-centered

Goals

• Goal to improve the quality of life for the patient and family
• Interdisciplinary approach.
• Appropriate at any stage, age in serious illness, can be provided with curative treatment
• Elderly patient population can benefit from this service

Hospice Care

• A program of care designed to support a patient and family in the last 6 months of life.
• Uses palliative care principles to support the patient and family.
• Generally covered by insurance.
• Important data about hospice in 2011 includes 44.6% received hospice, 35% died within 7 days, and median stay was 21 days.

Criteria for Determining Decline in Clinical Status

• Criteria to consider:
• Weight loss not due to reversible causes
• Recurrent or intractable infections
• Recurrent aspiration or inadequate oral intake
• Progressive decline in Karnofsky Performance status.
• Progressing dementia by objective measures
• Progressive pressure ulcers

Karnofsky Performance Status Scale

• This is a tool that facilitates the assessment of the patients and their functionality

Advance Care Planning

• Understand the patients preferences and goals.
• Determine the person to make decisions when the patient cannot
• Kind of medical treatment a patient wants or does not want
• Determine level of comfort, how people should be treated by the patient
• What patients want their loved ones to know.

POLST vs Advance Directive

• POLST is for seriously ill patients and focuses on current care, completed by healthcare professionals, resulting in medical orders.

• Advance Directives are for all adults and deal with future care.

• POLST Can engage medical powers of attorney in a discussion if the patient lacks capacity

• In this care advance directives make the patient and family responsible

These flashcards cover the causes, types, and management of dehydration in elderly patients. Topics include proportionate loss of sodium and water, medication-related dehydration, heart failure management, and electrolyte imbalances. Also, they cover diabetes insipidus and assessments for dehydration.