• Dehydration, A Silent Killer of Nursing Home Residents
  • July 20, 2011
  • Law Firm: Slater Zurz LLP - Akron Office
  • Data from the 1996 National Hospital Discharge Survey show that 208,000 patients 65 years of age and older were discharged from short-stay hospitals with a primary diagnosis of dehydration. (Vital and Health Statistics. Vital and Health Statistics from the Centers for Disease Control and Prevention/National Center for Health Statistics. Detailed Diagnoses and Procedures, National Hospital Discharge Survey 1991.)

    Dehydration is a condition when the body is losing more water than it is taking in. Dehydration is defined as the depletion of total body water (TBW) content due to pathologic fluid loss or decreased fluid intake and is associated with high mortality rates among the elderly population in nursing homes.( Sansevero, AC. Dehydration in the elderly: strategies for prevention and management. Nurse Practitioner. 1997;22 (4): 41-72). Elderly dehydration is especially common for a number of reasons: some medications, such as for high blood pressure or anti-depressants, are diuretic; some medications may cause patients to sweat more; a person’s sense of thirst becomes less acute as they age; frail seniors have a harder time getting up to get a drink when they’re thirsty, or they rely on caregivers who can’t sense that they need fluids; and as we age our bodies lose kidney function and are less able to conserve fluid (this is progressive from around the age of 50, but becomes more acute and noticeable over the age of 70). Illness, especially one that causes vomiting and/or diarrhea, also can cause elderly dehydration.

    There are various complications to the health of nursing home residents that are associated with dehydration they include: Kidney failure, a common occurrence, although if it is due to dehydration and is treated early, it is often reversible, (as dehydration progresses, the volume of fluid in the blood decreases, and blood pressure may fall, this can decrease blood flow to vital organs like the kidneys, and like any organ with a decreased blood flow; it has the potential to fail); Coma, decreased blood supply to the brain may cause confusion and has been documented to cause comas; Shock, when the fluid loss overwhelms the body's ability to compensate, blood flow and oxygen delivery to the body's vital organs become inadequate and cell and organ function can begin to fail; Electrolyte abnormalities, in dehydration, electrolyte abnormalities often occur since important chemicals (like sodium, potassium, and chloride) are lost from the body, this has been shown to cause muscle weakness and heart rhythm disturbances; and unfortunately all too often, Death.

    One may wonder if there are guidelines in place that apply to nursing homes, as in most cases serious complications and deaths associated with dehydration are preventable. There are guidelines and the failure to follow them is defined as neglect by federal law. According to the Nursing Home Reform Act of 1987, the lack of assistance with eating and drinking, which leads to malnutrition and dehydration, is listed under neglect (Neglect and Abuse. Consumer Information Sheet, National Citizen's Coalition for Nursing Home Reform web site http://www.nccnhr.org 2000).

    There are also several statutes that establish guidelines for the detection and prevention of dehydration in the nursing home population. One of which is the Omnibus Budget Reconciliation Act (OBRA) which established dehydration/fluid maintenance triggers to alert staff of dehydration in long-term care residents and highlight the need to implement dehydration intervention. Unfortunately, even with these laws and regulations, dehydration is still attributed to the many deaths of nursing home residents.

    Medical studies have pointed to inadequate staffing and lack of professional supervision as factors contributing to dehydration in nursing homes. Kayser-Jones J, Schell ES, Porter C, Barbaccia JC, Shaw H. in a 1999 study, published in the Journal of American Geriatric Society at J Am Geriatr Soc. 1999 Oct;47(10):1187-94, revealed that 39 out of 40 studied nursing home patients received inadequate amounts of fluids during each of the days that they were followed. They published the following results:

    The residents' mean fluid intake was inadequate; 39 of the 40 residents consumed less than 1500 mL/day. Using three established standards, we found that the fluid intake was inadequate for nearly all of the residents. ... Clinical (undiagnosed dysphagia, cognitive and functional impairment, lack of pain management), sociocultural (lack of social support, inability to speak English, and lack of attention to individual beverage preferences), and institutional factors (an inadequate number of knowledgeable staff and lack of supervision of certified nursing assistants by professional staff) contributed to low fluid intake. During the data collection, 25 of the 40 residents had illnesses/conditions that may have been related to dehydration.

    Their conclusions were also compelling, and their advice simple, more staff, more education, more time spent with each resident.

    CONCLUSIONS:

    When staffing is inadequate and supervision is poor, residents with moderate to severe dysphagia, severe cognitive and functional impairment, aphasia or inability to speak English, and a lack of family or friends to assist them at mealtime are at great risk for dehydration. Adequate fluid intake can be achieved by simple interventions such as offering residents preferred liquids systematically and by having an adequate number of supervised staff help them to drink while properly positioned.

    What is even more striking is that, the staffing level in the nursing home in the above study was one nurse’s aide to every ten patients. Ohio’s minimum level is one nurse’s aide to no more than fifteen patients. In the above study the nurse’s aides were overwhelmed, staff tried to save time to be more efficient during their shift even if it was at the expense of quality care toward the elderly residents. One staff member even admitted to restricting fluids in order to reduce the urinary output of incontinent patients (and thus avoid changing wet beds). The study found that of those residents who received assistance, most were fed in 5 to 10 minutes while lying in bed on their sides, one patient, who had cognitive and functional impairment as a result of a stroke, ate her meals in a reclining position without assistance and this patient instead of drinking her fluids she dipped her fingers into her juice and licked them to avoid spills. With a patient to aide ratio 50% greater under Ohio law, a person can surmise that patient hydration needs suffer even more.

    The problem of dehydration is not only complicated by failures of adequate staffing and reporting, but also, by the failure of nursing home personnel to recognize signs and symptoms of dehydration.

    In another study the knowledge of the nursing staff was tested on the subject of signs and symptoms of dehydration by having them complete questionnaires that addressed hydration of the elderly. Only registered nurses were able to recognize even 50% of the signs and symptoms of dehydration.

    Education, appropriate staffing, and consistent monitoring of residents actual intake appear to be avenues that could greatly help in the prevention or early recognition of dehydration, allowing time for effective interventions without drastic health complications for the nursing home resident.

    In the mean time if dehydration has resulted in serious health complications for a resident in a nursing home, in all probability it constitutes legal neglect under both state and federal law.