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" - EDucAIING IHE OLDER ADULT IN THE PREVENTION

DETECTION AND TREATMENT OF EARLY
' STAGE DEHYDRATION

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ScholarIy Protect for the Degree of M S N
MICHIGAN STATE UNIVERSITY
KAREN R STEWART

1998 ' ’ * I

 

 

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6/01 cJCIRC/DaIeDuepss-p. 15

 

EDUCATING THE OLDER ADULT IN THE PREVENTION, DETECTION, AND
TREATMENT OF EARLY STAGE DEHYDRATION

By

Karen R. Stewart

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1998

ABSTRACT
Educating the Older Adult in the Prevention, Detection, and Treatment of Early Stage
Dehydration
By

Karen R. Stewart

Dehydration is a common, serious, and costly medical problem. The elderly are
at particular risk for dehydration due to normal aging changes, an increased incidence of
chronic diseases, and an increased vulnerability to acute illnesses such as influenza and
pneumonia. Unfortunately, dehydration often goes undetected until its later stages when
hospitalization is required. Though prevalent, dehydration is largely preventable and in
the initial stages, easily treated. Therefore, an emphasis on educating those at high risk
about preventive measures is imperative. For those instances when dehydration has not
been prevented, the ability to recognize dehydration in its early stages and intervene
quickly can prevent the high morbidity and mortality associated with the condition.
Educating the elderly is critical in terms of health maintenance and illness prevention. It
is necessary to provide information to older individuals that will assist them to maintain
optimal independence and quality of life. Such information can be provided in the form
of an educational brochure and if utilized will hopefiilly aid in reducing the number of

cases of dehydration reported in a community.

DEDICATION
I would like to dedicate this scholarly project to my husband, Eric, and our daughters,
Lindsay and Samantha. This goal has been reached because of your love and your faith
in me. Your support, encouragement, and cooperation over the past three and a half

years have made this project an accomplishment for all of us.

ACKNOWLEDGEMENTS

I would like to thank my scholarly project committee for the support,
encouragement, commitment, and expertise that have helped bring this project to fruition.
Their input and guidance have been invaluable. My sincere appreciation goes to Sharon
King, PhD, RN, 08., my Project Chairperson and Program Advisor, who has been a
true mentor throughout my graduate education. Her positive and caring attitude, together
with her patience, cheerleading, and humor has made this an enjoyable learning
experience. Special thanks go to Louise Selanders, Ed.D., R.N., for her critical eye and
editorial skills and to Laura Struble, PhD, RN ., OS for providing needed information
and helping to clarify concepts.

To my entire family and close friends, I extend my heartfelt gratitude for your
prayers and words of encouragement. For those of you who suffered through being the
subject of physical exams, I thank you.

Finally, to my dear friend and colleague, Judy Brady, who pushed me into this
program, I thank you. We proved to be quite a team throughout this process and I hope

that we can find the opportunity to work together in the future.

TABLE OF CONTENTS

List of figures .......................................................................... vi
Introduction ............................................................................. 1
Purpose of the project ................................................................. 3
Conceptual Framework ............................................................... 3
Figure 1 ................................................................................. 4
Figure 2 ................................................................................. 8
Literature Review ..................................................................... 10
Project Plan ............................................................................ 21
Implications for Advanced Practice ................................................ 26
Conclusion ............................................................................ 28
Appendix ............................................................................. 29

List of References .................................................................... 33

LIST OF FIGURES

Figure 1: The Health Belief Model

Figure 2: The application of the Health Belief Model to an educational brochure
regarding dehydration in the elderly

vi

INTRODUCTION

Dehydration is a common disorder among the elderly (Sansavero, 1997; Warren
et al., 1994; Weinberg, Minaker, & the Council on Scientific Affairs, American Medical
Association, 1995). In 1991, the Health Care Financing Administration ranked
dehydration as one of the most frequent diagnosis for Medicare hospitalizations (Health
Care Financing Administration, unpublished data). The actual incidence is probably
much higher, as dehydration may be masked by other clinical disorders and not listed as a
diagnosis even when present. It has been estimated that approximately 1.5% of
community dwelling elderly will be hospitalized with dehydration annually (Warren,
Harris, & Phillips, 1996).

Dehydration is frequently associated with an increased morbidity and mortality
rate. Stachenfeld, DiPietro, Nadel, and Mack (1997) state that dehydration may trigger a
cascade of adverse events initiating or accelerating a process leading to a severe
deterioration in health status. Dehydration can cause serious and troublesome health
problems such as renal failure and constipation. Dehydration has also been implicated in
the increased incidence of skin breakdown, falls, and changes in mental status.
Furthermore, one study reported that almost 50% of elderly Medicare beneficiaries
hospitalized with a principle diagnosis of dehydration died within a year of admission
(Warren et al., 1994). Such data indicate that dehydration in the elderly is a frequent,
serious, and costly medical problem. Although serious, Hoffman (1991) states

dehydration ofien goes unrecognized.

Current demographics project that by the year 2000, persons over 65 will
represent 13% of the United States population and that this percentage will more than
double by the year 2050 (Administration on Aging, 1997; US. Census Bureau, 1995).
As the number of elderly persons increases the importance of dehydration as a serious
medical problem is also likely to increase. Recognizing the incidence, risks, and
consequences associated with dehydration increases the need for strategies to prevent the
condition or to recognize and treat it in its early stages. Unfortunately, discerning
dehydration in the elderly can be difficult because many of the classic signs of
dehydration, such as sunken eyes and loss of skin turgor, are present among normally
hydrated older populations (Sansavero, 1997). This indicates a need for age-specific
assessment guidelines. This is important because if dehydration is identified early and
prompt treatment is instituted health outcomes can be dramatically affected.

Changes in the health care arena have impacted the way those in primary care
provide, manage, and evaluate their services (Starfield, 1992). Managed care is a system
created, in part, to control what is spent on health care while still maintaining quality of
care. Reimbursement is designed to provide incentives toward our becoming better
stewards of the resources at our disposal. Care is shifting from a focus on disease
treatment to a focus on primary and preventive care. Subsequently, teaching patients
how to manage and promote health takes on added importance. Accountability for
quality, cost-effective health care must be shared among health plans, health care
providers, and consumers. Consumers must be viewed as partners with accountability for
prevention. Consumers, therefore, need to be given health information if they are to

make informed decisions and be held accountable. Advanced practice nurses (APNs), in

their role as primary care provider (PCP), will be health care consumers’ initial contact
with the health care system. This places the APN in an ideal position to provide the
needed health information.
Purpose of the project

The purpose of this project is to develop a tool to educate community dwelling
elderly health care consumers regarding the risk factors, consequences, signs and
symptoms, and preventive measures related to dehydration in order to prevent the
morbidity and mortality associated with this condition. The segment of the elderly
population living independently and not in controlled environments that monitor blood
pressure, pulse rates, mental status, intake and output, and laboratory tests need accurate
and useable information to guide them in maintaining their health and independence.
Education is the key to preventing initial episodes or the reoccurrence of dehydration
among elderly populations. Although aimed at the consumer, this tool will hopefully
increase health care provider awareness of this issue and their need to assess for
dehydration and to educate the public about preventive meaures. To facilitate the
development of this tool, the Health Belief Model (HBM) will be used as a conceptual
fiamework (Janz & Becker, 1984; Pender, 1996).

CONCEPTUAL FRAMEWORK

The HBM (see Figure 1) is used as a framework for developing a tool aimed at
the prevention and early detection and treatment of dehydration in the elderly population.
The HBM is applicable to the concept of health protection because it focuses on efforts to
move away from or avoid the negative events associated with illness and injury. Both

primary prevention, that provides specific protection against disease and secondary

Individual Perceptions

Modifiying Factors

 

 

Perceived susceptibility
to disease X

Perceived seriousness
(severity) of disease
X

 

 

Demographic variables
(age, race, sex, ethnicity,
etc.)

Sociopsychologic
variables

(personality, social class,
peer and reference-group
pressure, etc.)

Structural variables
(knowledge about the
disease, prior contact
with the disease, etc.)

Likelihood of Action

 

Perceived benefits
of preventive action

_> ManS

Perceived barriers to
preventive action

 

 

 

 

 

 

i

Perceived threat of
disease X

I

 

 

Likelihood of taking
recommended
preventive health
action

 

 

 

 

 

Cues to action
Mass media
campaigns
Advice from others
Reminder postcards
from physician or
dentist
Illness of family
member or friend
Newspaper or
magazine article

 

 

Figure 1. The Health Belief Model. (From Pender, NJ. (1996). Health Promotion in
Nursing Practice (3rd ed.) Stamford, Connecticut: Appleton & Lange, pg. 36)

 

prevention, consisting of screening efforts and education that prompts early detection and
intervention, are addressed in the HBM.

The HBM offers a method for understanding health-related behavior that is
necessary if one is trying to predict, influence, and facilitate certain health behaviors. The
HBM contends that whether or not an individual undertakes a recommended health action
is dependent upon that person’s perceptions of their susceptibility to the particular illness
or condition and the degree of severity of the consequences that may result from the
illness or condition (Janz & Becker, 1984; Pender, 1996). In other words, the individual
must feel threatened in order to initiate a health action. Furthermore, the individual must
believe the health action has potential benefits in preventing or decreasing their
susceptibility and/or the severity of the illness or condition. In addition, the barriers to
initiating or continuing the proposed actions must be acceptable to the individual.

The HBM further asserts that a cue to action must occur to stimulate or trigger the
health action. In essence, it is this cue to action that makes the individual aware of the
health threat. The modifying factors within the model influence an individual’s
perceptions regarding risks and benefits. Consequently, if the level of readiness to act
(susceptibility and severity) is high and the negative aspects or barriers are low or weak
the health action is more likely to be acted upon. The amount of cue necessary is related
to the level of readiness; the lower the level of readiness the greater the cue needed.

The HBM assumes that “health” is a highly valued concern or goal for most
individuals. When considering preventive health behavior, susceptibility, benefits, and

barriers have consistently been associated with outcomes, barriers being the most

predictive. On the other hand, severity is more meaningful for patients who are
experiencing symptoms already or who have been diagnosed (Janz & Becker, 1984).

E The major constructs of the HBM include susceptibility, severity, benefits,
barriers, modifying factors, and cues to action. The definitions of these constructs clarify
the support this model gives to the development of a tool aimed at the prevention and
early detection and treatment of dehydration in the elderly.

Susceptibility refers to the person’s subjective perception of the risks of
contracting a condition (Janz & Becker, 1984). Severity involves the feelings regarding
the seriousness of contracting an illness. This construct includes evaluations of both
medical and clinical consequences (e. g. death, pain, disability) and potential social
consequences (e. g. effects on social relationships and family life, move to nursing home,
loss of independence) that individuals believe the health condition would create for them.
Benefits depend on the beliefs regarding the effectiveness of the various actions available
in preventing or reducing the disease threat. Barriers involve the potential negative
aspects of a particular health action (e. g. cost, inconvenience, pain, side effects, and
complexity of regime). There is a cost-benefit analysis that is done when considering the
benefits and barriers of a health action. Modifying factors include demographic factors
(age, sex, race, etc), sociopsychological variables (personality, peer pressure, social
class, etc), and structural variables (knowledge of disease, prior experience with disease).
Cues to action include anything that triggers a health action. Cues may be internal
(i.e.symptoms) or external (i.e.mass media, interpersonal communication, reminder

postcards, and flyers).

The HBM constructs are used to define the components required in an educational
tool in order to initiate or affect a change in health behavior (see Figure 2). Susceptibility
is the first construct to be addressed. A person must feel they are at risk if an action is to
be taken. Someone who has experienced poor health is more likely to perceive health
threats from an illness/condition than someone who has experienced excellent health
(Burns, 1992). It can be assumed that most elderly have experienced some health
deviation over the years. This will increase their sense of vulnerability. Pointing out
simple yet overwhelming statistics regarding the risks of dehydration for the elderly will
increase their perception of susceptibility. In addition, providing information about the
reasons for an older adult’s increased risk of dehydration will also impact perception of
susceptibility.

An individual’s perception of severity will be affected by their current health
status. Statistics can also be used to affect perceptions of dehydration’s severity. A focus
on potential consequences related to dehydration can further impact an individual’s
perception of severity.

To increase perceived benefits, health actions must demonstrate effectiveness in
reducing or preventing dehydration. Recognition of signs and symptoms of dehydration
can lead to early detection and intervention thus impacting the potential morbility and
mortality associated with dehydration. Therefore, a listing of signs and symptoms in the
teaching tool is indicated. Current treatment strategies for dehydration should also be
utilized in the proposed tool.

Barriers are the strongest predictor of an individual’s taking/declining a health

action (Janz & Becker, 1984). The higher the perceived barrier, the less likely an

Individual Perceptions

Modifiying Factors

Likelihood of Action

 

 

 

Demographic variables
(increasing age, race, sex,
ethnicity, etc.)
Sociopsychologic
variables

(personality, social class,
peer and reference-group
pressure, etc.)

Structural variables
(knowledge about
dehydration, prior contact
with dehydration, etc.)

 

Effectiveness of health
action in reducing or
preventing dehydration

-Recognition of signs
and symptoms

-Simplicity,
convenience, and cost of
intervention

 

 

 

 

-Statistics related to risks
and consequences of
dehydration
-Information related to an
older adult’s increased
risk of dehydration
-Information about the
consequences of
dehydration

-Current health status
including acute illnesses
and chronic diseases

 

l

 

Perceived threat of
—> dehydration

 

 

 

i

 

Cue to action

 

 

 

Educational brochure

 

 

l

 

 

Likelihood of taking
recommended
preventive health
action

 

 

 

Figure 2. The application of the Health Belief Model to an educational brochure
regarding dehydration in the elderly.

individual will take the proposed action. Consequently, health actions to prevent or treat
early dehydration will need to be simple, convenient, and inexpensive if there is to be an
increased likelihood of being followed. The individual must believe they have the ability
to influence their health status. However, when a health practice is easy to accomplish no
major concentration on efficacy is needed (Rosenstock, 1988).

Modifying factors include the target population’s demographics. Since the aged
population (those 65 years of age and older) are the ones targeted it is imperative that the
tool used be written with the characteristics of the aged in mind. Some physical changes
of aging that need to be considered when developing a written educational tool include a
decreased ability to discriminate blues and greens due to the yellowing of the iris and a
decrease in visual acuity. A sociopsychological variable to be considered is that of peer
pressure. Increasing exposure to material through postings or distribution of materials in
various sites frequented by elders will increase awareness and stimulate conversations
among elders regarding the risks and means of prevention. Support and urgings from
family and close friends are significantly related to preventive health behavior. Providing
individuals with information regarding dehydration can influence structural variables.
Only if one is aware of a health danger will action be taken to avoid it.

The written educational tool would be considered an external cue to action with
its goal being to trigger certain health actions to prevent dehydration and its sequelae or
intervene in its early stages. Ample cues need to be supplied to increase the sense of
susceptibility and perceived severity. Timing for distribution of the educational tool

could aid the impact of the cue (i.e. during flu season, hot weather).

10

LITERATURE REVIEW

The constructs of the HBM are used to define the components that need to be
addressed in an educational tool designed to aid the prevention and early detection and
treatment of dehydration in the elderly. In a review of the literature, the substance of the
tool is clearly identified. It is within the literature review that the problem of dehydration
is defined and the causes, risk factors, signs and symptoms, consequences, and treatments
for dehydration are summarized. Furthermore, the review of the literature addresses the
impact of this condition on quality of life and health care costs and supports the need for
consumer education if prevention and early detection and treatment are to be realized.
Dehydration: I’Jathogiysiolgmnd Definition

Dehydration is a fluid and electrolyte imbalance. It involves the relationship
between sodium and water. Water imbalances may develop due to changes in salt
concentration and sodium imbalances occur with alterations in body water volume
(Heuther, 1994). A basic concept to fluid and electrolyte balance is osmolarity, or solute
concentration. Water moves between intracellular and extracellular fluid compartments
in the direction of greater concentration of solutes. This is known as osmosis. The intake
or elimination of fluid directly influences plasma osmolarity, hence the role of thirst and
urinary losses in fluid balance. Plasma osmolarity increases when there is a water deficit
or an increase in sodium (Sansavero, 1997).

Water balance involves a complex interplay and overlapping roles of the kidneys,
adrenal glands, and endocrine system (Kositzke, 1990). These are the organs responsible

for the production and secretion of aldosterone, antidiuretic hormone (ADH), and renin-

ll

angiotensin. Aldosterone regulates sodium balance by increasing the reabsorption of
sodium and secretion of potassium by the distal tubule of the kidney (Heuther, 1994',
Sansavero, 1997). Aldosterone’s secretion is controlled by the circulating blood volume
and plasma concentrations of sodium and potassium. Aldosterone is secreted when
sodium levels are depressed or when potassium levels are increased.

ADH is the regulating factor for water balance as it is secreted in response to
increases in serum osmolarity or decreases in blood volume (Heuther, 1994; Sansavero,
1997). When ADH is secreted, renal tubules are more permeable to water, thus more
water is reabsorbed and plasma osmolarity is decreased.

The renin-angiotensin system is activated by reduced circulating blood volume
and decreased perfitsion of the renal vasculature (Heuther, 1994). This system stimulates
the secretion of aldosterone and causes vasoconstriction. Vasoconstriction restores renal
perfiision by elevating the systemic blood pressure.

Dehydration is defined based on the pathophysiology of fluid balance. Gross et
al. (1992) and Sansavero (1997) define dehydration as depletion in total body water.
Weinberg et al. (1995) define dehydration as a rapid weight loss of more than 3% of body
weight. Heuther (1994) states dehydration is a term used to describe water deficit and
also to indicate a sodium and water loss. Hypernatremic dehydration is the most
common type of dehydration in the elderly population (Gross et al.) and is due to
inadequate intake of fluids or excessive fluid losses. Therefore, for the purpose of this
project dehydration will be defined as a fluid volume deficit due to insufficient fluid

intake, pathological fluid losses, or both.

 

12

Risk Factors

The risk factors for dehydration that are identified in the literature impact an
individual’s perception of susceptibility. Awareness of risk factors impacts the
individual’s ability to prevent dehydration by taking action before signs and symptoms
develop. Any disease, illness, personal factor, or environmental situation that causes
excessive fluid loss or insufficient fluid intake places an individual at risk for
dehydration.

Age-related changes. Increased age is one of the major risk factors for
dehydration. Individuals 85—99 years of age are six times more likely to be hospitalized
with dehydration than those 65-69 years of age (Warren et al., 1994). Dehydration is a
common problem in older persons because the aging process is often accompanied by a
misregulation of the physiological mechanisms that would counteract excessive changes
in body water. For instance, there is a decreased sensation of thirst and a decreased
ability to concentrate urine as we age (Ayus & Arieff, 1996; Hoffman, 1991; Leaf, 1984;
Phillips et al., 1991; Sansavero, 1997; Stachenfeld et al., 1997; Weinberg et al., 1995).
The thirst mechanism is vital since fluid intake is the only way of replacing a deficit of
water. Thirst is believed to diminish with aging due to alterations in oropharyngeal
sensations or central nervous system disorders (Phillips et al.). The decreased ability to
concentrate urine is due to the gradual loss of glomeruli that results in a decreased
filtering surface. ADH responds to increases in serum osmolarity or decreases in
circulating blood volume. Yet, this hormone also undergoes a diminished efl’ect as we
age (Sansavero). The elderly are also more susceptible to dehydration because they have

a decrease in total body water content as a proportion of body weight due to decreased

l3

muscle mass (Ayus & Arieff, Sansavero). Muscle holds 40% of total body water
(Lavizzo-Mourey, 1987). An elder’s decreased sense of taste and smell can dampen the
desire for food and fluids firrther impacting their vulnerability to dehydration.

Chronic physical and/or mental disafilities. Diagnosis such as depression,
dementia, arthritis, and stroke can predispose an individual to dehydration (Hoffman,
1991; Silver, 1990; Sansavero, 1997; Weinberg et al., 1995). Physical and mental
disabilities can impose limits on the ability to physically access water or to communicate
the need for fluid. Strokes and other neurologic disorders cause fluid regulation problems
by affecting the fimctioning of the hypothalamus and pituitary gland thus impacting the
thirst sensation (Kositzke, 1990). There may be a fear of aspiration due to dysphagia that
causes an individual to limit their fluid intake. In addition, fluids may be intentionally
restricted in order to limit incontinence, thus predisposing an individual to dehydration
(Kositzke).

Acute illnesses. Older adults are more susceptible to acute illnesses, in part due to
age-related immune system dysfunction (Bennett & Greenough, 1993). Pneumonia,
urinary tract infections, influenza, and gastroenteritis are risk factors for dehydration
(Hoffman, 1991; Sansavero, 1997; Warren et al., 1994). Loss of fluid can occur due to
fever, tachypnea, diaphoresis, diarrhea, and vomiting. Antibiotics used to treat infections
can also cause diarrhea. A change in functional status due to an acute illness may further
predispose an individual to dehydration by impacting the ability to access fluid.

Chronic diseases. The elderly are more likely than their younger counterparts to
have chronic diseases and be on multiple medications. The diseases that are considered to

put individuals at risk for dehydration include congestive heart failure, hypertension, and

l4

renal diseases due to their effect on renal perfusion (Sansavero, 1997; Warren et al.,
1994). Diabetes, when uncontrolled, can cause intravascular fluid volume depletion
through osmotic diuresis from glycosuria (Lorber,1995). Medications that raise glucose
levels by inhibiting the secretion or action of insulin can adversely affect diabetic control,
thus impacting fluid balance. These medications include corticosteroids, propranolol,
phenytoin, and cimetidine (Lorber). Other medications that have the potential to cause
problems with fluid balance include diuretics, laxatives, antacids, antipsychotics, major
tranquilizers, sedatives, nonsteroidal antiinflamatory drugs, and hypertonic contrast dyes.
Diuretics, as their name implies, influence fluid balance by causing diuresis. Laxatives
and antacids can induce diarrhea. The antipsychotics, major tranquilizers, and sedatives
can adversely affect the desire to drink fluids. Nonsteroidal antiinflammatory drugs
impact fluid and electrolyte balance and cause renal vasoconstriction by inhibiting
prostaglandin synthesis. Hypertonic contrast dyes used in diagnostic studies may cause
an osmotic diuresis.

Miscellaneous factors. Other risk factors for dehydration include previous
episodes of dehydration, anorexia, excessive alcohol intake, and excessive caffeine intake
(Hoffman, 1991). High protein tube feedings, a lack of access to health care or follow-
up, limited finances to purchase food and fluids, and a lack of air conditioning during hot
weather have also been implicated as risk factors for dehydration (Sansavero, 1997;
Vassallo, Gera, & Allen, 1994; Weinberg et al., 1995).

Consequences
Complications and other consequences associated with dehydration will impact an

individual’s perception of severity. Warren et al. (1994) concluded from their study that

15

older people, men, and blacks were at higher risk for hospitalization with dehydration. In
addition, the study found that 50% of elderly Medicare beneficiaries that were
hospitalized with a principle diagnosis of dehydration died within a year of admission,
with 17.4% dying within 30 days of admission. Mortality rates increased with age.

When cells within the body are unable to maintain normal volume their structure
and function are affected (Ayus & Arieff, 1996). The body’s loss of normal cellular
function predispose individuals to health problems such as infections, renal failure,
decreased skin turgor with skin breakdown, and cognitive impairment. Other
consequences associated with dehydration include functional decline, feelings of
weakness, falls, and constipation with impaction (Hoffman, 1991; Sansavero, 1997).
Cognitive impairment, firnctional decline, and falls may also impact an individual’s
ability to live independently.
Signs and Symptoms

Recognition of signs and symptoms of dehydration by the elder is important if
early identification and intervention is to be accomplished. Being able to recognize early
dehydration and begin treatment that prevents potential morbidity and mortality impacts
an elder’s perception of the benefits of their health action. In addition, if an elder
believes that signs and symptoms suggest a problem with their hydration status they can
seek firrther work-up from their primary care provider. Unfortunately, the literature
states that there are few signs and symptoms unique to dehydration. Many may be
attributed to aging and coexisting disorders. Furthermore, signs and symptoms may be

vague, deceptive, or absent in the elderly (Weinberg et al., 1995). It is for this reason that

l6

Pals et al. (1995) suggests using changes in firnction and oral fluid intake to determine
hydration status.

According to Heuther (1994), the signs associated with dehydration include thirst,
dry skin and mucous membranes, elevated temperature, weight loss, and concentrated
urine. Sansavero (1997) lists the classic signs of dehydration as skin tenting,
concentrated urine, oliguria, sunken eyes, lack of axillary moisture, and orthostatic blood
pressure and pulse changes. These signs are somewhat vague and do not take into
consideration the changes associated with aging. Gross et al. (1992) did look at age in
determining risk factors for dehydration. It was determined from their study that the
clinical indicators for dehydration in the elderly include: upper body muscle weakness,
speech difficulty, dry mucous membranes of nose and mouth, longitudinal tongue
furrows, confusion, and sunken appearance of eyes in their sockets.

Many potential signs of dehydration are detected through an examination of the
mouth. In the study by Gross et al. (1992), tongue furrows and dry mucous membranes
were among the strongest correlates of dehydration and were even present in over 70% of
older adults with mild dehydration and in 100% of older adults with severe dehydration.
Dryness of tongue, tongue coating, and absent salivary pools have also been highly
correlated with dehydration (Aaronson & Seamen, 1989; Sansavero, 1997). However, a
dry mouth can be related to mouth breathing, drug side effects, and anxiety (Gross et a1).

Loss of skin turgor and sunken eyes though often associated with dehydration are
generally considered unreliable indicators for the elderly due to a loss of skin elasticity
with aging. Evaluation of turgor over the forehead or sternum affords slightly more

accuracy in determining dehydration in this population.

l7

Vital signs and weight measurements can also be used to evaluate hydration
status. Orthostatic blood pressure and pulse measurements are considered fairly reliable
in detecting dehydration in the elderly but changes in these measurements may also result
from certain medications, deconditioning related toprolonged bedrest, or cardiovascular
and neurological illnesses (Bennett &Greenough, 1993; Warren et al., 1994; Weinberg et
al., 1995). Weight loss of 5% of body weight in the past 30 days or 10% loss in 6 months
should trigger an evaluation for dehydration (Weinberg et al.). Baseline weights would
be necessary for this to be an effective measurement. A less accurate method of noting
weight loss would be observing changes in the way clothing fits.

Additional clinical indicators of dehydration include mental status changes,
deterioration in functional ability, weakness, and dizziness. One should also be alerted to
evaluate for dehydration if individuals complain of nausea, anorexia, headache, vomiting,
and syncope.

Certain laboratory tests that can help detect dehydration include electrolytes,
osmolality, creatinine, blood urea nitrogen (BUN), BUN/creatinine ratio, hematocrit, and
urine specific gravity. A serum sodium level greater than 148 mmol/liter indicates
dehydration but may also be noted in other disease states. Significant dehydration can be
present even when hyponatremia (sodium levels less than 135 mmol/liter) is present.
This is known as hypotonic dehydration. Sodium loss can exceed water loss due to
overuse of diuretics. Vomiting and diarrhea can lead to isotonic dehydration where there
is a balanced loss of sodium and water. Elevated creatinines are associated with
dehydration. However, patients with muscle wasting that has resulted in chronically low

serum creatinines can have normal serum creatinines when they are dehydrated (Bennett

 

18

& Greenough, 1993). Ratios of blood urea nitrogen to creatinine of 25 or more may be
found in dehydrated individuals (Pals et al., 1995; Sansavero, 1997; Weinberg et al.,
1995). However, a high ratio may also be found in patients with renal disease,
obstructive uropathy, and steroid induced catabolism. An elevated hematocrit suggests
dehydration but may be in the normal range in dehydrated patients with anemia. Urine T
specific gravity increases with a fluid volume deficit. Urine output generally decreases

with dehydration and urine becomes concentrated.

 

No single sign or symptom will strongly correlate with dehydration. However, if ’
several signs and/or symptoms are present an accurate diagnosis of dehydration is more
likely. Due to the vague and sometimes absense of clinical indicators for dehydration in
the elderly, it is reasonable to educate older adults to question the possibility of
inadequate hydration if they note a change in functional ability or baseline status.
Prevention and Treatment

The complexity of health actions to prevent or treat dehydration positively
correlates with an individual’s perception of barriers. As perceived barriers increase an
individual is less likely to follow through with a health action. The literature indicates
that dehydration can easily be prevented and easily treated in its early stages. When
dehydration becomes moderate to severe, treatment often requires hospitalization for
intravenous fluid replacement (Sansavero, 1997).

Prevention of dehydration can be achieved simply by maintaining an adequate
fluid intake. The literature suggests that this intake needs to range from 1500-2500 cc per
day (Hoffman, 1991; Sansavero, 1997; Weinberg et al., 1995). The specific amount of

fluid required would be based on the individual’s weight, urinary and fecal losses, and

l9

insensible losses due to lung vapor and sweat. Weinberg et al. state that the estimated
daily fluid requirement for geriatric patients is 30 mL per kilogram of body weight.
Fluids should be taken with meals and also between meals. Fluid excess needs to be
considered in patients with diseases such as congestive heart failure, cirrhosis, and
nephrotic syndrome. Water is the preferred liquid and should constitute half of one’s
fluid intake. Other fluids that can be used include fruit/vegetable juices, milk, soft drinks,
sport drinks, and soup. The type of fluids used may be based on individual preference
and other comorbidities. Alcohol and caffeinated beverages should be avoided due to
their diuretic action.

Warren et al. (1994) suggest that the incidence of dehydration may be reduced or
prevented by vaccination against influenza and pneumonia. This is appropriate because
respiratory illnesses and dehydration have been strongly associated with one another.
Furthermore, maintaining adequate fluid intake during acute illnesses such as
gastroenteritis is essential as significant fluid losses can occur due to diarrhea.

Other preventive measures include the use of fans and airconditioners, obtaining
bedside commodes, raised toilet seats, and adaptive devices, and evaluating support
services. The use of fans and air conditioners during hot weather may help prevent
dehydration by decreasing the insensible loss of fluids via perspiration and tachypnea that
occurs when body temperature increases. Assistance obtaining bedside commodes or
raised toilet seats may prevent individuals from limiting fluids due to difficulty getting to
or using the bathroom. Obtaining adaptive devices for elders with dexterity problems can

enhance their ability to obtain fluids. Finally, evaluating availability of support services

20

to address financial concerns and determining eligibility for such services as meals on
wheels may prevent dehydration by making sure adequate food and fluids are available.

Monitoring and control of one’s diabetes, CHF, hypertension, and renal disease is
essential to preventing dehydration since poor control is often associated with an
increased incidence of dehydration. A periodic review of medications and their side
effects is also warrented. Elimination, limited use, or close monitoring of those
medications known to be problematic for fluid balance should be considered. Periodic
electrolyte evaluation is suggested for high-risk patients in order to detect dehydration in
its early stages (Sansavero, 1997). Evaluation of fluid intake at office visits may also
detect risk for dehydration and prompt education and intervention. For those patients who
refuse to eat and drink a dietary referral and an evaluation for underlying cause such as
depression may be indicated.

In summary, the literature review reveals dehydration to be a common and serious
medical problem with dire financial and health consequences. The risk of dehydration
for elders is significant due to age-related changes and predisposition to chronic diseases.
The consequences of dehydration are serious and can range from constipation to
cognitive and functional impairment and even death. The signs and symptoms of
dehydration are often vague and may be absent in the elderly. One must therefore be
vigilant to observe subtle changes and remain aware that dehydration is always possible.
Prevention, early detection, and treatment are essential if significant morbidity and
mortality from dehydration is to be avoided. Prevention is always preferred and this
requires education. Elderly individuals need to be taught about their risks for dehydration

and the consequences related to this condition. Signs and symptoms of dehydration as

21

well as prevention and early intervention strategies also need to be included in the
educational process.
PROJECT PLAN

The development of an educational tool to prevent dehydration and to identify and
intervene in its early stages is based on the HBM and a review of the literature.
Increasing awareness of the problem of dehydration and education about this condition is
considered essential if the associated morbidity and mortality is to be avoided. Based on
the conceptual model and literature review the items to include in the tool are: risk
factors, consequences, signs and symptoms, and prevention and treatment strategies. The
elderly are targeted because the literature indicates that dehydration is a significant health
problem for this population. Tiivel (1997) states that education of the older adult is
critical if health is to be maintained and illness prevented. The goal of imparting
information about dehydration is to aid community dwelling elders to maintain optimal
independence and quality of life by preventing the serious consequences of dehydration.
As it is increasingly difficult for the PCP to find time to impart needed information, the
use of written materials to educate and reinforce instruction is needed.

A pamphlet format is utilized in presenting information because it is easily
distributed in a variety of settings and can, therefore, reach many people in a cost-
effective manner. Furthermore, individuals can look at a pamphlet when it is convenient
for them and when they feel they are ready for the information. Although not a substitute
for individualized instruction from one’s PCP, a pamphlet can instigate discussions with
the provider, reinforce instruction, and enhance understanding. An informed elder may

also seek care fi’om their PCP in a timely manner. According to Barlow and Wright

22

(1998) informational pamphlets can be effective in promoting longer-term increases in
knowledge and be a source of reassurance without evidence of adverse reactions.

In developing a pamphlet for the elderly, age-related changes need to be
considered. As we age there is a decreased ability to discriminate blues and greens due to
a yellowing of the iris. There is also a decrease in visual acuity. Awareness of these
physical changes helps to prompt the choice of paper color and font style and size.
Petterson (1994) suggests that employing typeface less than 12 point is not appropriate
for elders. Using a type size large enough to be legible to those with poor visual acuity
will restrict the amount of information that can be put into a brochure but this also limits
the information to the essentials.

The Gunning FOG test is a simple and reliable means of determining the
readability of written work (Petterson, 1994). A score is provided which helps to
determine the clarity of the language used. Petterson concludes that a FOG Index score
of 12 or above may be incomprehensible to the elderly. However, the Gunning FOG test
is restricted to continuous text and therefore may not be suitable for evaluating pamphlets
that do not have this format. Petterson states that using short words, short sentences, and
short paragraphs should produce increasingly readable documents. Further evidence
pointing to the need for providing simply written educational materials is provided by
Weirich et al. (1994) who conclude from their study that written materials for older adults
should be adapted to the fifth grade reading level. This is recommended because the
average educational level of the study population was the eighth grade, similar to the
profile of older Americans who are poor, less educated than the general population, and

predominantly female. According to Mayeaux et al. (1996), physicians tend to give too

23

much information on too high a level for many patients to understand. Using simpler
language, avoiding too many directives, and repeating the instruction can enhance
patients’ understanding. In addition, combining easy to read educational materials with
oral instruction augments understanding. Patient education materials should be short,
simple, and encourage desired behavior especially for individuals with low literacy skills
(Mayeaux et al.). Personalizing the information in leaflets also appears to improve
readability (Albert & Chadwick, 1992).

According to the Profile of Older Americans: 1997 (Administration on Aging,
1997), the educational level of the older population is increasing. The percentage of
elders who had completed high school rose from 28% to 64% between 1970 and 1995.
However, even with the increases noted in educational level, it is still valid to keep
instructions simple and short so that the greatest number of individuals can understand
and benefit from them.

Once the brochure has been produced it can be distributed to senior centers,
primary care clinics, senior housing units, and hospitals in a defined geographical
location. They will need to be placed in an area that is visible and accessable to
individuals. In the primary care clinics, providers will be given a brief inservice on the
contents of the brochure with recommendations to distribute the brochures to all high-risk
patients. PCPs will also be requested to document distribution of the brochure so that the
brochure’s effectiveness can be evaluated at a later date. Brochures in the other locations
will be out on display but not personally distributed to individuals. By initially limiting
distribution, evaluation of the brochure’s effectiveness in meeting its intended goals can

more easily be accomplished.

24

EVALUATION

Although disease related leaflets and brochures are widely available and
often used to supplement verbal instruction, their impact on patient knowledge and health
actions has seldom been evaluated (Barlow, Bishop, & Pennington, 1996). In order to
evaluate the effectiveness of this brochure one needs to determine the extent to which the
goals of the brochure were met. This is known as an outcomes analysis and this type of
evaluation tends to be descriptive and does not use a rigorous design (Polit & Hungler,
1995). The goals for the proposed educational brochure on dehydration are to increase
awareness of dehydration as a significant medical problem of the elderly, educate older
adults about risk factors, consequences, signs and symptoms, prevention, and treatment
of dehydration, and decrease the incidence of hospitalization, morbidity, and mortality
associated with dehydration through prevention, early detection, and intervention.

Increased awareness of dehydration as a significant medical problem of the
elderly can be grossly evaluated by determining the number of brochures picked up or
given out by providers from the sites of distribution. This method of evaluation assumes
that the brochures have been read. Surveys that directly ask about the impact of the
brochure on an individual’s awareness of the problem of dehydration could be completed
at sites that had brochures. Direct questioning of providers at the initial inservice of the
brochures about its impact on their awareness of dehydration as a significant problem for
older adults could also be used to evaluate the brochure’s effectiveness.
An older adult’s knowledge of the risk factors, consequences, signs and

symptoms, prevention, and treatment of dehydration can be evaluated by administering a

follow-up questionaire or survey to those individuals known to have received a brochure.

25

This would be done most easily at a primary care practice that documented who was
given a brochure. Another method that could be used for evaluation would be a pre and
post test, given to these same individuals, that evaluated knowledge gained from
information supplied in the brochure.

To evaluate the impact on health outcomes, a chart review at primary care
practices could be done before and after distribution of the brochure that focused on the
numbers of individuals being seen with signs and symptoms of dehydration, diagnosed
with dehydration, and requiring treatment for dehydration. Caution would be necessary
in interpreting results of these reviews since an increase in documentation of dehydration
could be due to an increased awareness of the issue and increased evaluations for
dehydration. Telephone logs at primary care practices could also be reviewed to
determine the number of calls triaged related to dehydration symptoms and questions.
Chart audits that indicated the number of hospital admissions and emergency room visits
related to dehydration could be done both before and after distribution of the brochures to
determine if the frequency of treatment and admissions for dehydration was affected. In
order to evaluate the impact of the brochure on an older adult’s behavior related to
preventive care and early intervention, a questionaire or phone survey could be used that
evaluated current health practices. Areas that could be evaluated include daily fluid
intake, status of vaccinations against influenza and pneumonia, use of adaptive devices if
appropriate, self-evaluation for signs of dehydration, adherence to medication regime
including use of laxatives and antacids, self-treatment methods for early dehydration, and

follow-up with PCP including the individual’s rationale for follow-up.

26

IMPLICATIONS FOR THE ADVANCED PRACTICE NURSE

Implications for Practice

The restructuring of the health care delivery system is creating many challenges
for the APN. PCPs are being challenged to provide quality health care in a cost-effective
manner and APNs are in a position to accomplish these goals. Educating the elderly
about the risks, consequences, signs and symptoms, prevention, and treatment of
dehydration can impact cost of care and quality of life. Most elderly reside
independently in the community and will seek health care from a PCP. It is imperative
that PCPs be able to provide quality care to their elderly clients. Since dehydration is a
common and serious problem for the aged population it is necessary that PCPs be able to
accurately assess elderly for dehydration and educate them regarding prevention, early
detection, and treatment of the condition. Utilization of educational materials that aid in
reinforcing the teaching that is begun by the PCP or that increases awareness of common
problems for the population is just one way the PCP can provide quality care in a cost-
effective manner. In addition, informed elders are more likely to be effective partners in
their care. Finally, it is because the PCP acts as a gatekeeper for those vulnerable to
dehydration that it is necessary that they know the predisposing factors for dehydration
and be able to implement preventive strategies whenever possible. By preventing or
treating dehydration in its early stages, morbidity and mortality associated with
dehydration will decline.
Implications for Education

The documented incidence rates for dehydration indicate that it is a frequently

seen condition among the elderly. Though largely preventable, the incidence rates for

27

hospitalizations due to dehydration are high. Apparently, dehydration is not being
detected in its early stages and preventive and treatment measures are not being instituted
in a timely fashion. Increased awareness of dehydration, as a serious medical problem,
needs to be addressed. The educational curriculum for all health care providers who will
care for geriatric clients should, therefore, include information about dehydration. By
educating future providers in the specific needs of the elderly, the likelihood of actually
meeting those needs is increased. Age specific assessment guidelines need to be
incorporated into the curriculums as well. Furthermore, education of currently practicing
providers regarding dehydration is needed. Continuing education courses could be one
avenue used to address this need. Awareness of incidence rates, risk factors, signs and
symptoms, and consequences related to dehydration can lead to early case finding and
treatment, thus impacting health care costs. Increasing awareness and educating the
public regarding dehydration, particularly those at high risk for the condition, should also
be goals. The methods of achieving these goals need to be explored. One possibility is
to include content on dehydration in discharge planning in the acute care setting.
Implications for Research

The literature review points to the paucity of research on strategies for prevention
and treatment of dehydration, effectiveness of early screening, and what tests or
observations should be used for early screening. Further research is also needed in the
area of age specific assessments as they impact diagnosis and treatment. Incorrect or
delayed treatment greatly impacts outcomes both in terms of cost and quality of life.
Additional research also needs to be done regarding the effectiveness of brochures as a

means of educating the public and influencing health behaviors. Other areas related to

28

brochures that could be researched include the impact of distribution methods and how
health care providers view and utilize brochures.
CONCLUSION

As the population ages, APNs will be caring for an increased number of elderly
patients. Therefore, it is important for the APN to understand common medical problems
of this age group. Dehydration is a common and serious medical problem for the elderly.
Although pervasive, dehydration is largely preventable. In the face of limited resources,
prevention and early intervention that maximizes functional status and quality of life is
desired. Education, then, becomes increasingly important as it is key to prevention. No
single educational strategy is effective for all patients. However, written materials that
can support verbal instruction and offer additional information have been shown to be
beneficial. Brochures are cost-effective as they are an inexpensive method of educating
the public and can be widely distributed, reaching a large number of people. It is through
educating the elderly about common health problems that they face and what they can do

about them that they can become true partners in their health care.

APPENDIX

29

APPENDIX

The Danger of Dehydration as We Age

What is dehydration?
Dehydration is a lack of fluid in your
body. You are too dry.

 

Can dehydration be bad for me?
Yes, because when you are

dehydrated you are more likely to:
get infections

develop kidney problems

become constipated

become weak and fall

have problems with your skin

become confused

be less able to care for yourself

DANGER

0F
What causes dehydration?

DEHYDRATION There are 2 main causes of
dehydration:

0 too much fluid is being lost from
AS the body
0 not enough fluid is being taken

WE AGE into the body

Causes of fluid loss:

0 diarrhea

o vomiting

0 perspiration

o medications (diuretics, antacids,
laxatives) that cause an increased
passage of urine or stools

 

30

o certain beverages (alcohol,
coffee, tea, soft drinks containing
caffeine)

0 fever

Reasons for not drinking enough

fluid:

0 do not feel thirsty

0 do not want to get up at night to
use the bathroom

0 concerns about incontinence

o difficulty getting water or other
beverage due to physical
limitations

0 fear of choking

o medications that affect the desire
to drink fluid (tranquilizers,
sedatives)

0 lack of appetite

0 cost of food and beverages

Why are older adults at greater

risk for dehydration?

As we age:

0 our sensation of thirst decreases
so that we don’t feel the need to
drink even when we are dry

0 our kidneys don’t work as well

0 we have a decreased sense of
taste and smell which limits our
desire to eat and drink

0 we have less water in our body so
that even small losses can have a
big impact

0 we are more likely to have
diseases that have a greater risk
for dehydration such as diabetes,
congestive heart failure, and
kidney disease

0 we are more likely to be on
medication that causes problems
with fluid balance

0 we are more prone to illnesses
such as influenza and pneumonia

0 we are more likely to have
physical problems that make it
difficult getting food and fluid

How can I tell if I’m dehydrated?
The classic signs of dehydration
(thirst, sunken eyes, decreased +/or
dark urine, dry skin) are sometimes
absent in the older adult. As we age,
one area that should be regularly
checked for signs of dryness is the
mouth.

You are probably too dry if:

0 the skin inside your mouth looks
dry

0 your tongue is dry or has deep
crevases or furrows in it

0 you have no saliva in your mouth
or your saliva is very thick

31

0 your tongue looks like it has a
coating on it

Other signs that may indicate a
lack of adequate fluids include:
o weakness

dizziness

headache

confusion

constipation

speech difficulty

Also be aware that you could be
dehydrated if you have lost
weight rapidly or if you notice a
decreased ability to carry out
your normal activities.

How can I prevent dehydration?

EU

DRINK! DRINK! DRINK!

   

0 Make sure you drink six to
eight 8-ounce glasses of fluid
each day.

-Water is preferred and should
make up at least V2 of your
fluid intake.

-A variety of other fluids that can
be used include fi'uit/vegetable
juices, milk, soft drinks, sport
drinks, and soup.
-Avoid alcohol and caffeinated
beverages.
-Do not limit your fluids to meal
times. Drink between meals as
well. '
-You will need to develop a habit
of drinking fluid since you may

~ not have thirst to remind you to
drink something.

'30 Important! If you have
congestive heart failure,
liver disease, or kidney
disease make sure you check
with your primary care
provider about the amount
of fluids you should be
drinking.

0 Get your vaccinations against
influenza and pneumonia

I'l'l

0 Use fans/air conditioners during
hot weather. During heat waves,

stay out of the sun, wear lighter
clothing, and drink more fluids.

 

Drink extra fluids before, during,

and after exercise to replace
fluids lost through perspiration
and heavy breathing.

TAMI

For those who limit fluids due to
difficulty getting to the bathroom
or using the toilet, obtaining a
bedside commode or raised toilet
seat may help.

If finances limit your ability to
purchase food or beverages, ask
your doctor, nurse, or social
worker for assistance in
determining your eligibility for

such services as meals on wheels.

Remember that water is the best
source of fluid and is
inexpensive.

Make sure you see your primary
care provider regulme to
monitor any chronic diseases

32

such as diabetes, congestive heart
failure, or kidney disease. It is
important to keep these diseases
well controlled.

0 Take your medications as they
are prescribed. Remember,
laxatives and antacids can cause
you to lose fluid by causing
diarrhea, so use cautiously.

 

When should I call or see my
primary care provider?

8

Contact your provider if:

0 symptoms of dehydration
persist longer than 2 days or
if your symptoms are
worsening

0 you are unable to eat or drink
for a full day

0 you are unsure if you are
dehydrated

@1998 Karen Stewart, RN, MSN

LIST OF REFERENCES

 

33

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