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Dehydration and Dysphagia: Challenges in the Older Adult
Abstract
The purpose of this article is to integrate current information regarding prevalence, risk factors, and management of dehydration. Dehydration is a pervasive condition affecting older adults in hospitals, long-term care facilities (LTC), and in the community. If left untreated, 50% of those with dehydration will die. Risk factors increase in the elderly because of physiological changes due to underlying disease processes. Dysphagia - inefficient or unsafe swallowing - is a known risk factor for dehydration. Dehydration management presents challenges. Approaches to prevent and manage dehydration, including those with dysphagia, are included.
... Among the elderly, diminished sensation of thirst as well as behavioral reasons such as fear of incontinence and/or disabling conditions associated with aging can contribute to dehydration risk. Age-associated decline in taste functions as well as swallowing disorders have also been recognized as contributing factors to dehydration risk among the elderly [44,45]. According to the United States' National Health and Nutrition Examination Survey (NHANES), in the period of 2009-2012, American adults, grouped by male and female genders, consumed an average daily amount of 3.46 L (males) and 2.75 L (females) of total water, with plain water and other dietary water (from food and other beverages) representing 30% (males) and 48% (females) of the total beverage intake [46]. ...
Characterization of taste- and flavor-producing metals, namely iron and copper, in drinking water is a multifaceted subject. Both metals are essential nutrients, can be toxic, and are known to produce unpleasant tastes and flavor sensations in drinking water. Ingestion of trace metal contaminants through drinking water is a probable source of human exposure. Biochemical mechanisms of metallic flavor perception have been previously described; however, less is known about how variations in salivary constituents might impact individuals’ sensitivities to metallic flavors and beverage consumption behaviors. This research presents findings from in vitro experiments, using artificial human saliva, to better understand the role of salivary lipids and proteins on metallic flavor production as measured by biomarkers of metal-induced oxidative stress. The results indicate that metal-induced lipid oxidation, as measured by thiobarbituric acid reactive substances (TBARS), is dominated by salivary proteins, is slightly inhibited in the presence of salivary nitrite, and is detectable by the TBARS method at and above respective concentrations of 9 µM (0.5 mg/L) and 90 µM (5 mg/L), which are both above the aesthetic standards for iron (0.3 mg/L) and copper (1.0 mg/L) in drinking water. Preliminary study with human subjects indicated that reduction in metallic flavor sensitivity, as measured by the best estimate flavor threshold for ferrous iron among 33 healthy adults aged 19–84 years old (22 females), corresponded with reduced drinking water consumption and increased caloric beverage intake among older subjects (>60 years), as determined by a validated self-reported beverage intake questionnaire. These findings provide insights for further research to examine how salivary constituents can impact humans’ sensory abilities in detecting metallic off-flavors in water, and how reduced metallic flavor sensitivity may influence beverage choices and drinking water consumption.
... Due to age-related health decline, the elderly are at increased risk for depression (ADA, 2005), cognitive impairment (Jones & Schell, 1997), and decrease in appetite (Castellanos, 2004). Dysphagia (trouble swallowing) (Bratlund, O'Donoghue, & Rocchiccioli, 2010; Miller & Carding, 2007; Kayser-Jones, 1997; Castellanos, 2004), decreased ability to taste and smell foods (White, 2005), and medication side effects are also known to increase risk for weight loss (Costellanos, 2004) and malnutrition (White, 2005). Further, research has shown that care provision is a contributing factor to intake, with low staffing levels and lack of training being associated with increased risk for undernutrition (Jones & Schell, 1997; Leydon & Dahl, 2008), as many residents need varying degrees of assistance from verbal encouragement to total dependence on staff, which requires both time and expertise (KayserJones & Schell, 1997). ...
Objective:
To explore the social organization of food provision in publicly funded and regulated long-term care facilities.
Methods:
Observations were conducted, along with 90 interviews with residents, families, and health providers in two Southern Ontario sites using rapid site-switching ethnography within a feminist political economy framework as part of an international, interdisciplinary study investigating healthy ageing.
Results:
Food is purchased within a daily $7.80/per resident allotment, limiting high quality choices, which is further problematized by privatization of food services. Funding restrictions also result in low staffing levels, creating tensions in aligning with other Ministry mandated tasks such as bathing, and documenting: competing demands often lead to rushed meals. Regulations, primarily set in response to scandals and to ensure appropriate measured nutrition, reinforce the problem. Further, regulations regarding set meal times result in lack of resident agency, which is compounded by fixed menu options and seating arrangements in one common dining room. Rather than being viewed as an important part of resident socialization, food is reduced to a medicalized task, organized within a climate of cost-containment.
Implications:
Findings warrant Ministry financial support for additional staff and for food provision. Policy changes are also required to give primacy to this population's quality of life.
... 29 Voluntary fluid restriction could also be related to fear of incontinence (in women and elderly persons), inconvenience of finding or being permitted access to restroom facilities, mobility status, 30 lack of safe and/or acceptable beverages, and inability to swallow. 31 Thus, drinking to thirst is a multifactorial behavior. ...
Water is an essential nutrient for all persons; thus, maintaining a chronic state of optimal hydration is recognized to provide health benefits. Fluid balance is maintained via thirst, a feedback-controlled variable, regulated acutely by central and peripheral mechanisms. However, voluntary drinking is also a behavior influenced by numerous social and psychological cues. Therefore, whether thirst-guided drinking maintains optimal hydration status is a multifactorial issue. Thirst perception is typically assessed by subjective ratings using either categorical or visual analog scales; however, which instrument yields greater sensitivity to change in hydration status has not been examined. Ratings of thirst perception do not always yield predictable patterns of voluntary drinking following dehydration; therefore, perceived thirst and ad libitum drinking are not equivalent measures of human thirst. The recommendation drink to thirst is frequently given to healthy individuals during daily life. However, factors and conditions (e.g., age, disease) that influence thirst should be recognized and probed further. (C) 2012 International Life Sciences Institute
Introduction and aim:
Oral hydration is essential in older adults as poor hydration can complicate existing medical conditions and increase morbidity. Older adults in surgical wards are at risk of dehydration due to insufficient fluid consumption. The aim of this project is to ensure patients aged 65 years and above are adequately hydrated.
Methods:
The current project was conducted over 7 months from February to August 2019 and involved pre and postimplementation audits to ensure compliance with best practice. The Joanna Briggs Institute Practical Application of Clinical Evidence System and the Getting Research into Practice tools were used as a guide. Audits were conducted at four surgical wards with a sample of 42 patients at each audit. The measures implemented include educating nurses on the importance of oral hydration in older adult patients and labelling water jugs to encourage fluid intake among these patients.
Results:
Nurses' compliance in monitoring older adult patients' daily fluid intake increased from 5 to 76% at follow-up audit (P < 0.05). In addition, the average amount of fluid consumed over 3 days increased from 858.23 to 1037.50 ml.
Conclusion:
This project demonstrated a significant increase in oral fluid intake among older adult patients during hospitalization and their understanding of adequate fluid intake. Nurses play an important role in ensuring adequate amounts of daily fluid intake by these patients.
Mealtimes are among the busiest times in nursing homes. Austerity measures resulting in insufficient staff with heavy workloads limit the amount of time available to assist residents with eating. Within a feminist political economy framework, rapid team-based ethnography was used for an international study involving six countries exploring promising practices and also for a study conducted in one Canadian province in which interrelationships between formal and informal care were investigated. Data collection methods included interviews and observations. In addition, dining maps were completed providing a cross-jurisdictional comparison of mealtime work organization, and illustrating the time spent assisting residents with meals. Dining maps highlight the reliance on unpaid care as well as how low staffing levels leave care providers rushing around, preventing a pleasurable resident dining experience, which is central to overall health and well-being.
The sensory and gastrointestinal changes that occur with ageing affect older adults' food and liquid intake. Any decreased liquid intake increases the risk for dehydration. This increased dehydration risk is compounded in older adults with dysphagia. The availability of a non-invasive and easily administered way to document hydration levels in older adults is critical, particularly for adults in residential care. This pilot study investigated the contribution of bioelectrical impedance analysis to measure hydration in 19 older women in residential care: 13 who viewed themselves as healthy and six with dysphagia. Mann-Whitney U analyses documented no significant between-group differences for Total Body Water (TBW), Fat Free Mass (FFM), Fat Mass (FM), and percentage Body Fat (%BF). However, when compared to previously published data for age-matched women, the TBW and FFM values of the two participant groups were notably less, and FM and %BF values were notably greater than expected. If results are confirmed through continued investigation, such findings may suggest that long-term care facilities are unique environments in which all older residents can be considered at-risk for dehydration and support the use of BIA as a non-invasive tool to assess and monitor their hydration status.
The risk for disordered oropharyngeal swallowing (dysphagia) increases with age. Loss of swallowing function can have devastating health implications, including dehydration, malnutrition, pneumonia, and reduced quality of life. Age-related changes increase risk for dysphagia. First, natural, healthy aging takes its toll on head and neck anatomy and physiologic and neural mechanisms underpinning swallowing function. This progression of change contributes to alterations in the swallowing in healthy older adults and is termed presbyphagia, naturally diminishing functional reserve. Second, disease prevalence increases with age, and dysphagia is a comorbidity of many age-related diseases and/or their treatments. Sensory changes, medication, sarcopenia, and age-related diseases are discussed herein. Recent findings that health complications are associated with dysphagia are presented. Nutrient requirements, fluid intake, and nutrition assessment for older adults are reviewed relative to dysphagia. Dysphagia screening and the pros and cons of tube feeding as a solution are discussed. Optimal intervention strategies for elders with dysphagia ranging from compensatory interventions to more rigorous exercise approaches are presented. Compelling evidence of improved functional swallowing and eating outcomes resulting from active rehabilitation focusing on increasing strength of head and neck musculature is provided. In summary, although oropharyngeal dysphagia may be life threatening, so are some of the traditional alternatives, particularly for frail, elderly patients. Although the state of the evidence calls for more research, this review indicates that the behavioral, dietary, and environmental modifications emerging in this past decade are compassionate, promising, and, in many cases, preferred alternatives to the always present option of tube feeding.
Inappropriate intravenous fluid therapy is a significant cause of patient morbidity and mortality and may result from either incorrect volume (too much or too little) or incorrect type of fluid. Fluid overload has no precise definition, but complications usually arise in the context of pre-existing cardiorespiratory disease and severe acute illness. Insufficient fluid administration is readily identified by signs and symptoms of inadequate circulation and decreased organ perfusion. Administration of the wrong type of fluid results in derangement of serum sodium concentration, which, if severe enough, leads to changes in cell volume and function, and may result in serious neurological injury. In patients whose condition is uncomplicated, we recommend a restrictive approach to perioperative intravenous fluid replacement, with initial avoidance of hypotonic fluids, and regular measurement of serum concentration of electrolytes, especially sodium.
There is no empirically derived consensus as to what food consistency types and method of food delivery (spoon, cup, straw) should be included in the videofluoroscopic swallowing (VFSS) studies. In the present study, we examine the rates of aspiration and pharyngeal retention in 190 dysphagic patients given thin (apple juice) and thick (apricot nectar) liquids delivered by teaspoon and cup and ultrathick (pudding-like) liquid delivered by teaspoon. Each patient was tested with each of the bolus/delivery method combinations. The fractions of patients exhibiting aspiration for each bolus/method of delivery combination were (1) thick liquids (cup), 13.2%; (2) thick liquids (spoon), 8.9%; (3) thin liquids (cup), 23.7%; (4) thin liquids (spoon), 15.8%, (5) ultrathick liquids (spoon), 5.8%. In each comparison [thick liquid (cup) vs. thick liquid (spoon), thin liquid (cup) vs. thin liquid (spoon), thick liquid (cup) vs. thin liquid (cup), thick liquid (spoon) vs. thin liquid (spoon), and thick liquid (spoon) vs. ultrathick liquid (spoon)], the p value for chi 2 was < 0.001. These results suggest that utilizing thin, thick, and ultrathick liquids and delivery by cup and spoon during a VFSS of a patient with mild or moderate dysphagia can increase the chances of identifying a consistency that the patient can swallow without aspirating and without pharyngeal retention after swallowing.
Dehydration has serious consequences for older adults, including increased risk of illness or death. This retrospective review of medical records describes the prevalence, assessment, and risk factors for chronic dehydration in 185 older adults who visited an emergency department in June 2000. Results showed chronic dehydration was present in 89 (48%) patients. Physicians documented assessment for signs of dehydration in 23 (26%) of the dehydrated older adults, but no independent assessments for dehydration were recorded by nurses. These findings indicate many older adults may suffer from unrecognized dehydration, and nurses should be alert to the possibility that dehydration may be present in community-dwelling older adults as well as those who live in residential facilities.
To determine the effects of an 8-week progressive lingual resistance exercise program on swallowing in older individuals, the most "at risk" group for dysphagia.
Prospective cohort intervention study.
Subjects were recruited from the community at large.
Ten healthy men and women aged 70 to 89.
Each subject performed an 8-week lingual resistance exercise program consisting of compressing an air-filled bulb between the tongue and hard palate.
At baseline and Week 8, each subject completed a videofluoroscopic swallowing evaluation for kinematic and bolus flow assessment of swallowing. Swallowing pressures and isometric pressures were collected at baseline and Weeks 2, 4, and 6. Four of the subjects also underwent oral magnetic resonance imaging (MRI) to measure lingual volume.
All subjects significantly increased their isometric and swallowing pressures. All subjects who had the MRI demonstrated increased lingual volume of an average of 5.1%.
The findings indicate that lingual resistance exercise is promising not only for preventing dysphagia due to sarcopenia, but also as a treatment strategy for patients with lingual weakness and swallowing disability due to frailty or other age-related conditions. The potential effect of lingual exercise on reducing dysphagia-related comorbidities (pneumonia, malnutrition, and dehydration) and healthcare costs while improving quality of life is encouraging.
The fluid recommendation for adults aged 70+ years has been criticised on the basis of a low prevalence of dehydration in community-dwelling older adults. This study explores whether the low prevalence might reflect limitations of individual dehydration indices.
Cross-sectional data on plasma sodium, blood urea nitrogen (BUN), creatinine, glucose and potassium were used to classify 1,737 participants of the 1992 Established Populations for Epidemiologic Studies of the Elderly (EPESE) (70+ years) according to multiple dehydration indices. Associations between dehydration indices, health and functional status were evaluated.
Depending on the indicator used, the prevalence of dehydration ranged from 0.5% for hypotonic hypovolaemia only (plasma tonicity < 285 mOsm l(-1) with orthostatic hypotension) to 60% with dehydration defined as either plasma sodium >or=145 mEq l(-1), BUN/creatinine ratio >or=20, tonicity >or=295 mOsm l(-1), or hypotonic hypovolaemia. Elevated tonicity and BUN/creatinine ratio were respectively associated with chronic disease and functional impairment.
The true prevalence of dehydration among community-dwelling adults may be low or high, depending on the indicator(s) used to define dehydration. Before we can pinpoint a generalisable prevalence of dehydration for community-dwelling seniors and draw conclusions about fluid recommendations, validation studies of dehydration indices and longitudinal studies of dehydration, health and functional status are needed.
Purpose of review The intake of water and electrolytes is inseparable from the ingestion of nutrients by normal or artificial means. Recent reports have agreed in criticizing the poor standards of practice and of training in the management of fluid and electrolyte balance, resulting in a large amount of avoidable morbidity, particularly in the elderly who are more vulnerable to fluctuations in body composition. Recent findings Ageing is associated with impaired physiological reserve and a reduced ability to compensate for fluctuations in environmental conditions. These changes include reduced cardiac and renal reserve, making the elderly more vulnerable to changes in water and electrolyte gain or loss with a resulting increase in morbidity and mortality. The ability to cope with errors in prescriptions is correspondingly diminished. Dehydration is a common problem in nursing homes and in the community, due often to failures in detection and appropriate management. In many cases, the cause is iatrogenic due to diuretics or drugs which impair the intake of food and fluid. Salt and water overload, particularly in hospital patients, is also common and results in impaired recovery from surgery and increased perioperative mortality and morbidity. Hyponatraemia is also an important clinical problem in hospital and the community. Summary Better training in the detection, prevention and management of fluid and electrolyte imbalance is needed to reduce common and serious morbidity associated with this problem to which the elderly are especially prone, owing to their diminished physiological reserves and increased comorbidity.
Purpose
This study is designed to describe the magnitude and economic burden of preventable hospitalizations primarily due to dehydration in the U.S. Prevention Quality Indicators (PQIs), developed by the Agency for Healthcare Research and Quality (AHRQ) are based on hospital inpatient data to provide insight into the quality of the health care systems outside the hospital setting. Hospitalization due to dehydration is avoidable with timely primary care; therefore, it has been used as one of the PQI. Although the dehydration is a preventable condition, it can lead to costly emergency room and hospital visits, and even death.
Methods
The 2004 National Hospital Discharge Survey, containing 370,785 inpatient records, was analyzed. This nationally representative survey is conducted annually under the auspice of the Centers for Disease Control and Prevention. Overall, the hospital response rate was 92%.
Results
In the year 2004, approximately 518,000 hospitalizations were primarily due to the dehydration. Nearly 5.5 billion dollars in hospital charges were resulted from dehydration admissions. Approximately 88% were either an emergency or urgent type admissions; over 54% were admitted to a hospital through the emergency room; nearly 2% of admissions died at the hospital.
Conclusion
Dehydration is a prime example of a preventable condition from hospitalization if the condition had been managed properly in primary health care. This study's results suggest that the cost burden resulting from avoidable hospitalizations due to dehydration is substantial. Improved primary health care would save substantial social and financial costs and possibly lives.
Dehydration is a serious risk for elders because total body water decreases with age, aging kidneys are less able to concentrate urine, and the sensation of thirst decreases. Geriatric nurses traditionally have assessed for dehydration, but its signs are difficult to detect in many patients. Instead, nurses, assistive personnel, and family members must work to prevent dehydration in elders. In contrast, dehydration may be beneficial to patients during the final stage of a terminal illness, although the decision to withhold or withdraw medical hydration may present a legal and ethical dilemma for nurses. (Geriatr Nurs 2000;21:84-7)
Dehydration in clinical practice, as opposed to a physiological definition, refers to the loss of body water, with or without salt, at a rate greater than the body can replace it. We argue that the clinical definition for dehydration, ie, loss of total body water, addresses the medical needs of the patient most effectively. There are 2 types of dehydration, namely water loss dehydration (hyperosmolar, due either to increased sodium or glucose) and salt and water loss dehydration (hyponatremia). The diagnosis requires an appraisal of the patient and laboratory testing, clinical assessment, and knowledge of the patient's history. Long-term care facilities are reluctant to have practitioners make a diagnosis, in part because dehydration is a sentinel event thought to reflect poor care. Facilities should have an interdisciplinary educational focus on the prevention of dehydration in view of the poor outcomes associated with its development. We also argue that dehydration is rarely due to neglect from formal or informal caregivers, but rather results from a combination of physiological and disease processes. With the availability of recombinant hyaluronidase, subcutaneous infusion of fluids (hypodermoclysis) provides a better opportunity to treat mild to moderate dehydration in the nursing home and at home.
Studies amongst older people with acute dysphagic stroke requiring thickened fluids have assessed fluid intakes from combinations of beverage, food, enteral and parenteral sources, but not all sources simultaneously. The present study aimed to comprehensively assess total water intake from food, beverages, enteral and parenteral sources amongst dysphagic adult in-patients receiving thickened fluids.
Patients requiring thickened fluid following dysphagia diagnosis were recruited consecutively from a tertiary teaching hospital's medical and neurosurgical wards. Fluid intake from food and beverages was assessed by wastage, direct observation and quantified from enteral and parenteral sources through clinical medical records.
No patients achieved their calculated fluid requirements unless enteral or parenteral fluids were received. The mean daily fluid intake from food was greater than from beverages whether receiving diet alone (food: 807 +/- 363 mL, food and beverages: 370 +/- 179 mL; P < 0.001) or diet with enteral or parenteral fluid support (food: 455 +/- 408 mL, food and beverages: 263 +/- 232 mL; P < 0.001). Greater daily fluid intakes occurred when receiving enteral and parenteral fluid in addition to oral dietary intake, irrespective of age group, whether assistance was required, diagnosis and whether stage 3 or stage 2 thickened fluids were required (P < 0.05). After enteral and parenteral sources, food provided the most important contribution to daily fluid intakes.
The greatest contribution to oral fluid intake was from food, not beverages. Designing menus and food services that promote and encourage the enjoyment of fluid dense foods, in contrast to thickened beverages, may present an important way to improve fluid intakes of those with dysphagia. Supplemental enteral or parenteral fluid may be necessary to achieve minimum calculated fluid requirements.
Dehydration is the most common fluid and electrolyte disorder among the elderly, yet risk factors are not known. This study identifies risk factors for dehydration in acutely ill nursing home residents. All 339 elderly resident of two nursing homes who developed an acute illness requiring hospitalization during 1984 were included in the study. The 173 patients having a serum Na less than 150 mg/dL and blood urea nitrogen to creatinine ratio (BUN:Cre) less than 20 were designated controls; 91 patients having a serum Na greater than 150 mg/dL or a serum BUN:Cre greater than 25 were designated cases. Odds ratios (OR) and confidence intervals were calculated for age, sex, chronic conditions, acute illnesses, medications, functional status measures, and season. Acutely ill dehydrated patients were female (OR, 3.3); over 85 years old (OR, 2.2); had more than four chronic conditions (OR, 4.0); took more than four medications (OR, 2.8); and were bedridden (OR, 2.9). Among the most severely dehydrated (serum Na greater than 150 mg/dL and BUN:Cre greater than 25), the odds ratios for the above factors were strengthened and other factors, such as inability to feed oneself and type of acute diagnosis, emerged as risk factors. Among the variables unrelated to functional status, laxatives (OR, 3.2) and chronic infections (OR, 1.8) were risk factors. We conclude that a group at high risk for dehydration can be defined and that they are better characterized by the number of chronic diseases and debilitated functional status than by acute disease processes.
During times of scarce resources available for providing patient care, it becomes necessary to validate the effectiveness of standard practices that consume caregivers' time and efforts. Three nurse managers of nursing units serving diverse patient populations studied the effectiveness of continuous intake and output in estimating daily fluid balance. They examined 48-hour records of daily weight and intake and output of 73 patients and correlated the two. Their findings suggest that even when caregiver charting compliance is optimal, daily intake and output recording provides unreliable results. The authors recommend daily weights alone be adopted for all patients who are not experiencing acute renal conditions.
As a reduction of water spaces is expected in the elderly because of fat-free mass loss, disease is often associated with increased hydration. The present study compared water spaces and cellular hydration in adults, healthy and diseased aged patients.
An open study was conducted in 6 geriatric wards and a nutrition laboratory involving 85 aged diseased persons, 68 healthy elderly adults, and 35 adults. Total body water (TBW, H(2)(18)O dilution), extracellular water (ECW, Bromide dilution), and fat-free mass (FFM, body density and Siri's equation) were measured directly whereas intracellular water (ICW = TBW - ECW) and body cell mass (FFM - ECW) were obtained by calculations.
FFM, TBW, and ICW were higher in adults than in the 2 other groups and in the elderly than in aged patients. ECW was higher in aged patients than in healthy elderly participants. The proportion of TBW made of ECW or ICW was the same in adults and in healthy elderly persons. A higher proportion of TBW was composed of ECW, and a lower proportion of TBW was composed of ICW, in diseased patients compared with the 2 other groups. The proportion of ICW in body cell mass was also lower in diseased patients.
Diseased elderly persons display reduced ICW and expanded ECW. A cellular dehydration is suggested.
To investigate the fluid intakes of patients with dysphagic acute stroke and to evaluate the effect of disability, the ward speciality and the type of fluid given on oral intake.
Patients were prospectively recruited and randomly assigned to receive powder-thickened fluids or ready prepared pre-thickened fluids. Parenteral, enteral and oral fluid intakes, urine output, clinical sequelae and the frequency of requests for biochemical measures of hydration were recorded for a maximum of fourteen days.
24 patients with dysphagic acute stroke requiring thickened fluids were recruited from a large teaching hospital. Mean thickened fluid intake was 455 ml/d (SEM+/-70) resulting in the use of an extra 742 ml/d (+/-132) of supplementary fluids. This did not result in an adequate total intake due to insufficient volumes being given for too short a period. Patients not on specialist stroke units who received pre-thickened fluids drank almost 100% more than those on powder-thickened fluids (P=0.04).
Fluid intakes in this patient group are insufficient to achieve requirements. Hospital staff must ensure adequate fluid intakes in patients at risk of dehydration, which should include both an adequate prescription and provision of supplementary fluids. Pre-thickened drinks improve oral fluid intake in patients with dysphagic acute stroke on non-specialist wards.
To determine whether dysphagic stroke patients receiving oral (thickened-fluid dysphagia) diets or nonoral (enteral feedings supplemented with intravenous fluids) diets met their estimated fluid requirements.
Cohort study.
University-affiliated hospital.
Thirteen dysphagic patients with new strokes were studied for 21 days postadmission to hospital.
Seven patients (group 1) were started on nonoral feeding and later progressed to oral diets and 6 patients (group 2) received oral dysphagia diets only.
Fluid intake.
Fluid intake of patients in group 1 significantly declined over the 21 days (mean +/- standard deviation, 3158 +/- 523mL/d vs 984 +/- 486mL/d; p < .0001), representing 134% +/- 26% and 43% +/- 20% of their fluid requirements, respectively. Mean fluid intake of patients in group 2 was 755 +/- 162mL/d, representing 33% +/- 5% of requirements. This volume was significantly lower than the fluid intake of patients who received nonoral feeding (p < .0001).
Dysphagic stroke patients who received thickened-fluid dysphagia diets failed to meet their fluid requirements whereas patients on enteral feeding and intravenous fluid regimens received ample fluid.
Recreational enthusiasts and athletes often are advised to abstain from consuming caffeinated beverages (CB). The dual purposes of this review are to (a) critique controlled investigations regarding the effects of caffeine on dehydration and exercise performance, and (b) ascertain whether abstaining from CB is scientifically and physiologically justifiable. The literature indicates that caffeine consumption stimulates a mild diuresis similar to water, but there is no evidence of a fluid-electrolyte imbalance that is detrimental to exercise performance or health. Investigations comparing caffeine (100-680 mg) to water or placebo seldom found a statistical difference in urine volume. In the 10 studies reviewed, consumption of a CB resulted in 0-84% retention of the initial volume ingested, whereas consumption of water resulted in 0-81% retention. Further, tolerance to caffeine reduces the likelihood that a detrimental fluid-electrolyte imbalance will occur. The scientific literature suggests that athletes and recreational enthusiasts will not incur detrimental fluid-electrolyte imbalances if they consume CB in moderation and eat a typical U.S. diet. Sedentary members of the general public should be a less risk than athletes because their fluid losses via sweating are smaller.
Pressure ulcers are prevalent in nursing home residents. They heal slowly and result in pain and impaired quality of life. Strategies to enhance healing of pressure ulcers are critical to the treatment regime in nursing homes. This article explores the possibility that nursing home residents with pressure ulcers may experience low tissue oxygen and impaired hydration. Pilot data are presented suggesting that some proportion of nursing home residents with pressure ulcers experience low subcutaneous oxygen and that fluid administration increases the low tissue oxygen. Further research in this area is warranted.
The intake of water and electrolytes is inseparable from the ingestion of nutrients by normal or artificial means. Recent reports have agreed in criticizing the poor standards of practice and of training in the management of fluid and electrolyte balance, resulting in a large amount of avoidable morbidity, particularly in the elderly who are more vulnerable to fluctuations in body composition.
Ageing is associated with impaired physiological reserve and a reduced ability to compensate for fluctuations in environmental conditions. These changes include reduced cardiac and renal reserve, making the elderly more vulnerable to changes in water and electrolyte gain or loss with a resulting increase in morbidity and mortality. The ability to cope with errors in prescriptions is correspondingly diminished. Dehydration is a common problem in nursing homes and in the community, due often to failures in detection and appropriate management. In many cases, the cause is iatrogenic due to diuretics or drugs which impair the intake of food and fluid. Salt and water overload, particularly in hospital patients, is also common and results in impaired recovery from surgery and increased perioperative mortality and morbidity. Hyponatraemia is also an important clinical problem in hospital and the community.
Better training in the detection, prevention and management of fluid and electrolyte imbalance is needed to reduce common and serious morbidity associated with this problem to which the elderly are especially prone, owing to their diminished physiological reserves and increased comorbidity.
Dehydration is a frequent etiology of morbidity and mortality in elderly people. It causes the hospitalization of many patients and its outcome may be fatal. Indeed, dehydration is often linked to infection, and if it is overlooked, mortality may be over 50%. Older individuals have been shown to have a higher risk of developing dehydration than younger adults. Modifications in water metabolism with aging and fluid imbalance in the frail elderly are the main factors to consider in the prevention of dehydration. Particularly, a decrease in the fat free mass, which is hydrated and contains 73% water, is observed in the elderly due to losses in muscular mass, total body water, and bone mass. Since water intake is mainly stimulated by thirst, and since the thirst sensation decreases with aging, risk factors for dehydration are those that lead to a loss of autonomy or a loss of cognitive function that limit the access to beverages. The prevention of dehydration must be multidisciplinary. Caregivers and health care professionals should be constantly aware of the risk factors and signs of dehydration in elderly patients. Strategies to maintain normal hydration should comprise practical approaches to induce the elderly to drink enough. This can be accomplished by frequent encouragement to drink, by offering a wide variety of beverages, by advising to drink often rather than large amounts, and by adaptation of the environment and medications as necessary.
Recent data suggest that as many as 50% of older adults may have hypertonic plasma, an indicator of cell dehydration that predicts a range of adverse outcomes. To determine if a prevalence of this magnitude could be real, this study used nationally representative data to estimate the prevalence of hypertonicity, and to test for biologically plausible associations between hypertonicity, older age, glucose dysregulation, hemoconcentration, reduced bioelectrical impedance, and water intake.
Cross-sectional.
Community-dwelling adults (aged 20 to 90 years) who gave blood as part of the Third National Health and Nutrition Examination Survey (N = 14,855).
Plasma tonicity was estimated from glucose, sodium, and potassium values. The weighted prevalences of mild (295 to 300 mmol/L) and overt hypertonicity (> or = 300 mmol/L) were estimated by age, sex, race/ethnicity, fasting, and glycemic status. Hyper- and normotonic (285 to 295 mmol/L) groups were compared with respect to elevated blood chemistry values, bioelectrical impedance analysis parameters, as well as total water intake (grams, % Adequate Intake, and grams per kilogram body weight), using multivariable models that adjusted for age, sex, race/ethnicity, and survey design.
Mild and overt hypertonicity were observed in 40% and 20% of the sample, respectively. Hypertonicity was positively associated with older age, Hispanic and African-American race, impaired glucose tolerance, diabetes, and hemoconcentration, and inversely associated with bioelectrical impedance analysis parameters. Hypertonicity was associated with greater total water intake in younger adults, but decreased intake in older adults.
Clinicians and researchers should be alert to hypertonicity and its causes in older adults.
Dehydration is the most common fluid and electrolyte imbalance in older adults. The objectives were to identify the factors that increase the risk of dehydration in older adults, how best to assess the risk and manage oral fluid intake. Data sources included Medline, CINAHL, Cochrane Library, Embase and Current Contents, which were searched until February 2002. Randomized controlled trials for management of adequate fluid intake were undertaken. Cohort and case control studies were used for the identification of risk factors for dehydration. Studies of assessment tools for the identification of dehydration were also considered.
Results show that there is no clear determination of the risk factors for dehydration and decreased fluid intake. The recommended daily intake of fluids should be not less than 1600 mL/24 h in order to ensure adequate hydration. A fluid intake sheet and urine specific gravity might be the best methods of monitoring daily fluid intake. Regular presentation of fluids to bedridden older adults can maintain adequate hydration status. In conclusion, more research is required to determine the optimum method of maintaining adequate oral hydration in older adults.
Malnutrition and dehydration are potential consequences of dysphagia, a common swallowing disorder among elderly individuals. Providing smaller, more frequent meals has been suggested (but not demonstrated) to improve energy intake among this group. Accordingly, this study was designed to assess whether the same energy content in five vs three daily meals would improve energy intake. Thirty-seven residents of an extended-care facility, aged older than 65 years, previously evaluated for dysphagia, and receiving a texture-modified diet, agreed to participate in a crossover study with random assignment to three or five meals during an initial 4-day study period, followed by the opposite meal pattern in a second period. Six were excluded from analysis, as their medical condition deteriorated before or during the study. Food and fluids consumed by participants during each study period were weighed before and after each meal. Average energy intakes were similar between the three- and five-meal patterns (1,325+/-207 kcal/day vs 1,342+/-177 kcal/day, respectively; P=0.565); fluid intake was higher with five meals (698+/-156 mL/day) vs three (612+/-176 mL/day; P=0.003). Because offering five daily feedings did not improve energy intakes when compared with three, dietitians caring for this vulnerable group might need to consider other nutrition intervention strategies.
To assess the pathophysiology and treatment of neurogenic dysphagia.
46 patients with brain damage, 46 with neurodegenerative diseases and eight healthy volunteers were studied by videofluoroscopy while swallowing 3-20 mL liquid (20.4 mPa s), nectar (274.4 mPa s) and pudding (3931.2 mPa s) boluses.
Volunteers presented a safe and efficacious swallow, short swallow response (< or =740 ms), fast laryngeal closure (< or =160 ms) and strong bolus propulsion (> or =0.33 mJ). Brain damage patients presented: (i) 21.6% aspiration of liquids, reduced by nectar (10.5%) and pudding (5.3%) viscosity (P < 0.05) and (ii) 39.5% oropharyngeal residue. Neurodegenerative patients presented: (i) 16.2% aspiration of liquids, reduced by nectar (8.3%) and pudding (2.9%) viscosity (P < 0.05) and (ii) 44.4% oropharyngeal residue. Both group of patients presented prolonged swallow response (> or =806 ms) with a delay in laryngeal closure (> or =245 ms), and weak bolus propulsion forces (< or =0.20 mJ). Increasing viscosity did not affect timing of swallow response or bolus kinetic energy.
Patients with neurogenic dysphagia presented high prevalence of videofluoroscopic signs of impaired safety and efficacy of swallow, and were at high risk of respiratory and nutritional complications. Impaired safety is associated with slow oropharyngeal reconfiguration and impaired efficacy with low bolus propulsion. Increasing bolus viscosity greatly improves swallowing function in neurological patients.
Introduction:
Long-term care (LTC) residents, especially the orally fed with dysphagia, are prone to dehydration. The clinical consequences of dehydration are critical. The validity of the common laboratory parameters of hydration status is far from being absolute, especially so in the elderly. However, combinations of these indices are more reliable.
Objective:
Assessment of hydration status among elderly LTC residents with oropharyngeal dysphagia.
Methods:
A total of 28 orally fed patients with grade-2 feeding difficulties on the functional outcome swallowing scale (FOSS) and 67 naso-gastric tube (NGT)-fed LTC residents entered the study. The common laboratory, serum and urinary tests were used as indices of hydration status. The results were considered as indicative of dehydration and used as 'markers of dehydration', if they were above the accepted normal values.
Results:
The mean number of dehydration markers was significantly higher in the FOSS-2 group (3.8 +/- 1.3 vs. 2 +/- 1.4, p = 0.000). About 75% of these FOSS-2 patients had > or =4 dehydration markers versus 18% of the NGT-fed group (p = 0.000). A low urine output (<800 ml/day) was significantly more common in the FOSS-2 group (39 vs. 12%, p = 0.002). Above normal values of blood urea nitrogen (BUN), BUN/serum creatinine ratio (BUN/S(Cr)), urine/serum osmolality ratio (U/S(Osm)), and urine osmolality U(Osm), were significantly more frequent in the dehydration-prone FOSS-2 group. This combination of 4 indices was present in 65% of low urine output patients. In contrast, it was present in only 36% of the higher urine output patients (p = 0.01). Patients with a 'normal' daily urine output (>800 ml/day) also had a significant number (2 +/- 1.5) of positive indices of dehydration.
Conclusions:
Dehydration was found to be common among orally fed FOSS-2 LTC patients. Surprisingly, probable dehydration, although of a mild degree, was not a rarity among NGT-fed patients either. The combination of 4 parameters, BUN, BUN/S(Cr ), U/S(Osm) and U(Osm), offers reasonable reliability to be used as an indication of dehydration status in daily clinical practice.
To examine the effects of lingual exercise on swallowing recovery poststroke.
Prospective cohort intervention study, with 4- and 8-week follow-ups.
Dysphagia clinic, tertiary care center.
Ten stroke patients (n=6, acute: < or =3mo poststroke; n=4, chronic: >3mo poststroke), age 51 to 90 years (mean, 69.7y).
Subjects performed an 8-week isometric lingual exercise program by compressing an air-filled bulb between the tongue and the hard palate.
Isometric and swallowing lingual pressures, bolus flow parameters, diet, and a dysphagia-specific quality of life questionnaire were collected at baseline, week 4, and week 8. Three of the 10 subjects underwent magnetic resonance imaging at each time interval to measure lingual volume.
All subjects significantly increased isometric and swallowing pressures. Airway invasion was reduced for liquids. Two subjects increased lingual volume.
The findings indicate that lingual exercise enables acute and chronic dysphagic stroke patients to increase lingual strength with associated improvements in swallowing pressures, airway protection, and lingual volume.
Individuals with dysphagia are commonly provided with oral fluids thickened to prevent aspiration. Most thickening agents are either gum-based (guar or xanthan) or are derived from modified starches. There is evidence, predominantly anecdotal, that dysphagic individuals are subclinically dehydrated. Dysphagia has a particular impact on elderly individuals and there is justifiable concern for dehydration in this population. It has been speculated that dehydration may, in part, be the result of the water-holding capacity of these thickening agents decreasing water absorption from the gut. The aim of this study was to determine the rate of intestinal absorption of water from thickened fluids. The method used was a laboratory tracer study in rats and humans in vivo. We found that there were no significant differences in water absorption rates between thickened fluids or pure water irrespective of thickener type (modified maize starch, guar gum, or xanthan gum). These data provide no support for the view that the addition of thickening agents, irrespective of type, to orally ingested fluids significantly alters the absorption rate of water from the gut.