Dehydration in the Elderly: A Review Focused on Economic Burden

Breaking the Silence on Food Risks for Elderly People Living Alone

(1) Background: Currently, numerous qualitative research studies on food and its influence on health are being conducted. In qualitative research, data are obtained by analyzing participants' responses. However, silence during conversation has been little studied. The aim of this study was to interpret the silences in the narratives of elderly people living alone about the potential risks of not keeping a healthy diet. (2) Methods: This is a descriptive and interpretative observational study under the qualitative research paradigm following a phenomenological and ethnographic perspective. The study was developed in two phases with people over 65 years old. In the first phase, from June 2021 to January 2022, 90 interviews, 12 life history analyses, 58 food diaries and 51 free listings (cultural domain technique) were conducted. In the second phase, from March to June 2022, 3 participatory workshops and 24 pile sorts (cultural domain technique) were conducted, as well as 3 focus groups. Only data from participants over 65 years old living alone are analyzed in this paper. The ATLAS-ti (Version 22) qualitative analysis software was used for coding and data analysis. (3) Results: The results show that elderly people living alone would sometimes remain silent during the various conversations conducted within the research. This silence reflects their desire to downplay the risks to their health from not eating well due to their unwanted loneliness. The people participating in our research had chronic health problems, financial insecurity and emotional problems. (4) Conclusions: We concluded that elderly people living alone are unable to maintain a healthy diet because they downplay their risk of malnutrition. This mindset is caused by their loneliness and bolstered by a situation of learned helplessness and social injustice.

Impaired oral health: a required companion of bacterial aspiration pneumonia

Laryngotracheal aspiration has a widely-held reputation as a primary cause of lower respiratory infections, such as pneumonia, and is a major concern of care providers of the seriously ill orelderly frail patient. Laryngeal mechanical inefficiency resulting in aspiration into the lower respiratory tract, by itself, is not the cause of pneumonia. It is but one of several factors that must be present simultaneously for pneumonia to develop. Aspiration of oral and gastric contentsoccurs often in healthy people of all ages and without significant pulmonary consequences. Inthe seriously ill or elderly frail patient, higher concentrations of pathogens in the contents of theaspirate are the primary catalyst for pulmonary infection development if in an immunocompromised lower respiratory system. The oral cavity is a complex and ever changing eco-environment striving to maintain homogeneity among the numerous microbial communities inhabiting its surfaces. Poor maintenance of these surfaces to prevent infection can result inpathogenic changes to these microbial communities and, with subsequent proliferation, can altermicrobial communities in the tracheal and bronchial passages. Higher bacterial pathogen concentrations mixing with oral secretions, or with foods, when aspirated into an immunecompromised lower respiratory complex, may result in bacterial aspiration pneumonia development, or other respiratory or systemic diseases. A large volume of clinical evidence makes it clear that oral cleaning regimens, when used in caring for ill or frail patients in hospitals and long-term care facilities, drastically reduce the incidence of respiratory infection and death. The purpose of this narrative review is to examine oral health as a required causative companionin bacterial aspiration pneumonia development, and the effectiveness of oral infection control inthe prevention of this disease.

The value of improving freshwater ecosystem services: South Carolina residents' willingness to pay for improved water quality

Riverine ecosystems play a crucial role in providing essential services such as drinking water, food, recreation, and other aquatic resources. Yet, their capacity to deliver ecosystem services is threatened by rapid land use which modifies their ecological functions. While freshwater monitoring and restoration programs became more robust with technological advancement, the technical ecosystem indicators monitored by experts do not typically resonate with the public. Since public sentiments and preferences are crucial in conservation planning, we quantified households' mean willingness to pay (WTP) for riverine ecosystem services in South Carolina (SC) using a payment card approach. This technique in conducting a contingent valuation method allowed us to estimate mean WTP for five aquatic indicators. Findings revealed that households' monthly mean WTP is higher for indicators that can enhance recreational benefits, such as fish catch ($5.89- $6.58), species richness ($6.28- $6.72) and access ($6.75) compared to IBI ($5.74- $6.26) and instream flow quality ($5.34-6.06). When extrapolated to entire SC, the improvement of each indicator would translate to total benefits ranging between $131 to $165 million annually. The values computed from this study could serve as inputs for the computation of benefit-cost ratios of proposed freshwater programs. By incorporating households' WTP in the policy analysis, decision makers can prioritize programs that offer the greatest public benefit, while enhancing freshwater quality across the state.

Point-of-care ultrasound (POCUS) in acute hospitalized older patients focused on hydration

BACKGROUND

Acutely ill older patients frequently suffer not only from their acute disease, but also polymorbidity and frailty. Dehydration is another typical symptom, usually occurring in its both forms: low-intake dehydration and volume depletion. POCUS is goal-directed bedside ultrasound examination and several studies refer to its positive impact on hydration assessment. The aim of our study was to determine whether POCUS might influence (de)hydration diagnostics and/or treatments in older patients with acute illness.

METHODS

We randomized 120 acutely ill patients, aged ≥65 years, into POCUS and non-POCUS groups. All participants underwent routine laboratory tests, including haematocrit, serum and urine osmolality, blood urea nitrogen (BUN), creatinine, BUN/creatinine ratio, and C-reactive protein (CRP). POCUS was performed twice during the first two days to determine chest and abdominal status, with inferior vena cava (IVC) measurements. Length of hospital stay (HL) and consumption of infused fluids (CIF) was evaluated too. Data were analysed with exploratory methods and appropriate statistics.

RESULTS

Among all participants, the serum osmolality significantly correlated with age, BUN, creatinine and CIF. HL correlated with CRP and CIF. No significant correlations between IVC and other followed parameters were found. The POCUS group consumed significantly less infused fluids than the non-POCUS group, what could be influenced by POCUS examination of defined body compartments.

CONCLUSION

Dehydration is a common feature in older individuals and its diagnostics is rather complicated. The role of POCUS in assessing hydration status remains unclear. However, our study showed, that ultrasound assessment provides next important information for comprehensive understanding of clinical status in older patients and can be beneficial for optimizing the treatment strategy, including fluid management decisions.

Low-intake dehydration prevalence in non-hospitalised older adults: Systematic review and meta-analysis

BACKGROUND & AIMS

Low-intake dehydration amongst older people, caused by insufficient fluid intake, is associated with mortality, multiple long-term health conditions and hospitalisation. The prevalence of low-intake dehydration in older adults, and which groups are most at-risk, is unclear. We conducted a high-quality systematic review and meta-analysis, implementing an innovative methodology, to establish the prevalence of low-intake dehydration in older people (PROSPERO registration: CRD42021241252).

METHOD

We systematically searched Medline (Ovid), Cochrane CENTRAL, Embase (Ovid), CINAHL and Proquest from inception until April 2023 and Nutrition and Food Sciences until March 2021. We included studies that assessed hydration status for non-hospitalised participants aged ≥65 years, by directly-measured serum/plasma osmolality, calculated serum/plasma osmolarity and/or 24-h oral fluid intake. Inclusion, data extraction and risk of bias assessment was carried out independently in duplicate.

RESULTS

From 11,077 titles and abstracts, we included 61 (22,398 participants), including 44 in quality-effects meta-analysis. Meta-analysis suggested that 24% (95% CI: 0.07, 0.46) of older people were dehydrated (assessed using directly-measured osmolality >300 mOsm/kg, the most reliable measure). Subgroup analyses indicated that both long-term care residents (34%, 95% CI: 0.09, 0.61) and community-dwelling older adults (19%, 95% CI: 0.00, 0.48) were highly likely to be dehydrated. Those with more pre-existing illnesses (37%, 95% CI: 0.14, 0.62) had higher low-intake dehydration prevalence than others (15%, 95% CI: 0.00, 0.43), and there was a non-significant suggestion that those with renal impairment (42%, 95% CI: 0.23, 0.61) were more likely to be dehydrated than others (23%, 95% CI: 0.03, 0.47), but there were no clear differences in prevalence by age, sex, functional, cognitive or diabetic status. GRADE quality of evidence was low as to the exact prevalence due to high levels of heterogeneity between studies.

CONCLUSION

Quality-effects meta-analysis estimated that a quarter of non-hospitalised older people were dehydrated. Widely varying prevalence rates in individual studies, from both long-term care and community groups, highlight that dehydration is preventable amongst older people.

IMPLICATIONS

One in every 4 older adults has low-intake dehydration. As dehydration is serious and prevalent, research is needed to better understand drinking behaviour and assess effectiveness of drinking interventions for older people.

Dehydration and hospital-associated disability in acute hospitalized older adults

PURPOSE

Dehydration is highly prevalent in hospitalized older adults and has been linked to poor outcomes. It is considered a modifiable factor, so early identification and intervention may avoid adverse events and improve quality of life after discharge. Hospital-associated disability (HAD) is known to be a poor prognostic factor and can be categorized into mobility impairment and self-care impairment in setting goals for management. Few studies have directly examined the association between dehydration and HAD and therefore here we examined whether dehydration is a predictor of HAD categorized into mobility and self-care impairment among acute hospitalized older adults.

METHODS

Patients aged 65 years or older who were admitted to the geriatric ward of an acute hospital were recruited for this prospective cohort study. Estimated serum osmolarity > 300 mOsm/kg was defined as current dehydration. HAD was assessed between baseline and discharge and at 3 months after discharge, and was evaluated separately for mobility and self-care impairments.

RESULTS

In total, 192 patients (mean age, 84.7 years; male, 41.1%; dehydration, 31.3%) were analyzed. The occurrence of HAD was significantly higher in the dehydrated group than in the non-dehydrated group (42.4% vs 26.5%) from baseline to 3 months after discharge. In multiple logistic regression analysis, dehydration was significantly associated with HAD in self-care from baseline to 3 months after discharge (odds ratio, 2.25; 95% confidence interval, 1.03-4.94).

CONCLUSIONS

Dehydration could predict the occurrence of HAD in acute hospitalized older adults. A multifaceted approach may be necessary to improve the management of dehydration in these patients.

Overactive bladder: not just a normal part of getting older

Overactive bladder (OAB) is a common yet under-reported condition affecting both men and women. Prevalence rises with age, but OAB can affect people of any age. It is associated with increased physical and mental health problems and may lead to social isolation and escalating care needs. It is a clinical diagnosis with symptoms of urgency, with or without urge incontinence and usually with urinary frequency and nocturia. Management includes conservative, medical and surgical treatments, which can significantly improve quality of life. This review aims to raise awareness of this under-reported condition and to empower health professionals to open discussions on bladder health with all those in their care.

Adverse effects of subcutaneous vs intravenous hydration in older adults: An assessor-blinded randomised controlled trial (RCT)

BACKGROUND

Hydration therapy is essential in the care of the older patient. Subcutaneous (SC) hydration is a relevant method for parenteral hydration, but clinical trials on the subject have methodological shortcomings compared to updated standards.

DESIGN

Assessor-blinded, non-inferiority RCT to explore if SC is a safe alternative to intravenous (IV) hydration.

PARTICIPANTS

Eligible patients were: Admitted patients 65 years or older with a need for parenteral hydration. The targeted sample size was 67 patients in each group.

INTERVENTION

Patients were randomised to parenteral hydration via an IV or SC catheter during a 24 hours observation period. The non-randomised catheter (inactive) was placed as a sham on the patient, thereby blinding the caregivers and outcome assessors.

MEASUREMENT

Our primary outcome was the proportion of patients reporting at least one adverse effect with a non-inferiority calculation using a 20% margin.

RESULTS

We included 51 patients, with 24 randomised to SC and 27 to IV. We were unable to reach our target sample size due to challenges in recruitment, time limitation, and COVID-19. For the outcome of adverse effects, SC was non-inferior to IV (p = 0.012). Time spent on inserting the catheters was shorter with SC (p = 0.001). The groups did not differ by pain of insertion, discomfort during infusion, or the risk of developing delirium.

CONCLUSION

SC is a safe alternative to IV hydration, is faster to place and should be an available method for parenteral hydration wherever older adults are cared for.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03710408.

Haemodynamic frailty - A risk factor for acute kidney injury in the elderly

Clinical frailty in the elderly is defined by a composite measure of functional psychomotor decline. Herein, we develop the concept of haemodynamic frailty (HDF), a state of increased predisposition to disease prevalent in the elderly and characterised by impairment of the network of compensatory responses governing the defence of circulatory volume and adaptive haemodynamic function. We review the factors predisposing the elderly to HDF, with a focus on the impaired capacity to sustain total body water balance. As a component of HDF, dehydration generates vulnerability to diseases caused by tissue hypoperfusion, including acute kidney injury. We provide a detailed mechanistic explanation of how dehydration and depletion of the intravascular volume impacts on renal blood flow to become an important element of the heightened risk of acute kidney injury (AKI) in the elderly. We bring these mechanistic considerations into the clinical context with reference to examples of how pre-renal (haemodynamic) and intrinsic (involving renal parenchymal damage) AKI risk is elevated in the setting of dehydration. Finally, we present HDF as a state of opportunity to prevent disease, for which diagnostic and interventional standards need to be refined. Further prospective studies are warranted to help clarify the clinical utility of assessing and managing HDF with regard to the mitigation of AKI risk in the elderly.

Impaired hydration status in acutely admitted older patients: prevalence and impact on mortality

BACKGROUND

impaired hydration is common in the older people, however studies of its effects on outcome in the acute setting are limited.

OBJECTIVES

to assess (i) the prevalence of impaired hydration, (ii) its relationship with laboratory markers of altered hydration and with (iii) short- and long-term mortality.

DESIGN

retrospective cohort study.

SETTING

University Hospital-Internal Medicine Department.

SUBJECTS

a total of 5,113 older patients consecutively acutely admitted from October 2015 to July 2016.

METHODS

according to calculated serum osmolarity at admission hydration status was stratified in: low osmolarity (<275 mmol/L), euhydration (275-295 mmol/L), impending (296-300 mmol/L) and current dehydration (>300 mmol/L). Relationships with serum sodium, potassium, glucose, urea, estimated glomerular filtration rate (eGFR), haematocrit, urea/creatinine ratio (Urea/Cr) and urine specific gravity (USG) were determined. Charlson Comorbidity Index, Modified Early Warning Score, Glasgow Prognostic Score, Norton score and Nutritional Risk Screening-2002 were calculated.

RESULTS

current and impending dehydration, euhydration and low-osmolarity were detected in 51.7, 17.1, 28.5 and 2.7% of the patients, respectively. Osmolarity correlated with urea (r = 0.846). Associations with serum sodium, creatinine, eGFR and urea/Cr were low but significant, being negligible that with USG and haematocrit. Serum sodium and urea increased in the transition from low- to high-osmolarity (P < 0.001 in all pairwise comparisons). In multivariate modelling current dehydration, functional dependence, clinical instability and high nutritional risk were associated (P < 0.001) with reduced short- and long-term survival.

CONCLUSIONS

impaired hydration is common in older people acutely admitted to medical care and is associated with poor outcome. Early assessment of calculated serum osmolarity is mandatory to target dehydration and hypoosmolar disorders.

Dehydration in older people: A systematic review of the effects of dehydration on health outcomes, healthcare costs and cognitive performance

OBJECTIVE

To systematically examine the effect of dehydration on health outcomes, identify associated financial costs and consider impacts on cognitive performance in older adults.

DESIGN

A systematic review of English-language articles via OVID using MEDLINE, PsychINFO, EMBASE, and others, to March 2018. Included studies examined the relationship between hydration status and health, care costs or cognitive outcome.

SETTING

Cross sectional and cohort data from studies reporting on dehydration in older adults.

PARTICIPANTS

Adults aged 60 years and older.

MEASUREMENTS

Independent quality ratings were assessed for all extracted articles.

RESULTS

Of 1684 articles screened, 18 papers (N = 33,707) met inclusion criteria. Participants were recruited from hospital settings, medical long-term care centres and the community dwelling population. Data were synthesised using a narrative summary. Mortality rates were higher in dehydrated patients. Furthermore, health outcomes, including frailty, bradyarrhythmia, transient ischemic attacks, oral health and surgery recovery are linked to and worsened by dehydration. Length of hospital stay, either as a principal or secondary diagnosis, is greater in those with dehydration, compared to those who are euhydrated. Finally, neurocognitive functioning may be impacted by dehydration. There are issues with study design, inconsistency in hydration status measurement and different measures used for outcome assessment.

CONCLUSION

Dehydration in older people is associated with increased mortality, poorer course of illness and increased costs for health services. In addition, there is some, but sparse evidence that dehydration in older people is linked to poorer cognitive performance. Intervention studies should test strategies for reducing dehydration in older adults.

[Analysis of dehydration in older people in a nursing home in Spain: prevalence and associated factors]

Introduction

Background: dehydration in institutionalized elderly people has not been extensively studied. There are not clear data on the Spanish context. Aim: to estimate the prevalence of dehydration and to identify the associated factors in institutionalized older people in a nursing home. Methods: a cross-sectional study was carried out. Dehydration was measured through the colour of urine. For the identification of the associated factors, sociodemographic, clinical, functional, and mental variables were selected. Results: the total sample studied was comprised of 96 individuals with a mean age of 86.6 years (± 7.1), of whom 80.2 % were women. The prevalence of dehydration was 31.3% (95 % CI, 22.0 to 40.6). The factors that were independently associated with dehydration were the presence of sunken eyes (OR = 8.67; p = 0.004), low fluid intake (OR = 3.96; p = 0.041), and both functional (OR = 0.97; p = 0.012) and cognitive (OR = 1.10; p = 0.009) impairment. Conclusions: this study highlights the problem of dehydration in institutionalized older people in Spain. An urine colour table may be used routinely, non-invasively, and cheaply. So, it may well be the best simple method for detecting dehydration in this population. Taking into account that chronic dehydration is most prevalent in elderly people, the identification of associated factors is a key factor for a successful approach.

Nutrition behaviour and compliance with the Mediterranean diet pyramid recommendations: an Italian survey-based study

PURPOSE

Adopting a Mediterranean-like dietary pattern may help in preventing several chronic diseases. We assessed the eating behaviour and compliance with the Mediterranean diet pyramid recommendations in Italy.

METHODS

This is a cross-sectional study conducted in subjects aged ≥ 20 years. A 14-question survey based on the updated Mediterranean diet pyramid was launched online from April 2015 to November 2016. At test completion, a personalized pyramid displaying the possible deficiencies and/or excesses was generated, that could be the basis to plan diet and lifestyle modifications.

RESULTS

Overall, 27,540 subjects completed the survey: the proportion of females (75.6%), younger subjects (20.7%) and people with a University degree (33.1%) resembled those of the Italian population of Internet users rather than of the general population. 37.8% of participants declared a sedentary lifestyle, including 29.6% of those aged 20-29 years. A lower-than-recommended intake of all food categories included in the Mediterranean diet pyramid, along with excess of sweets, red and processed meats, emerged, that may affect health in the long term. Low adherence to recommendations was observed especially among females and older people. Notably, a discrepancy surfaced between the responders' perceived and actual behaviour toward the regular consumption of fruits and vegetables (81.8% vs 22.7-32.8%, respectively).

CONCLUSIONS

The nutritional habits and lifestyle of Italian participants are poorly adherent to the Mediterranean diet recommendations. The personalized pyramid tool may help in raising the awareness of individuals and their families on where to intervene, possibly with the support of healthcare professionals, to improve their behaviour.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Chronic Dehydration in Nursing Home Residents

Chronic dehydration mainly occurs due to insufficient fluid intake over a lengthy period of time, and nursing home residents are thought to be at high risk for chronic dehydration. However, few studies have investigated chronic dehydration, and new diagnostic methods are needed. Therefore, in this study, we aimed to identify risk factors for chronic dehydration by measuring serum osmolality in nursing home residents and also to evaluate whether examining the inferior vena cava (IVC) and determining the IVC collapsibility index (IVC-CI) by ultrasound can be helpful in the diagnosis of chronic dehydration. A total of 108 Japanese nursing home residents aged ≥65 years were recruited. IVC measurement was performed using a portable handheld ultrasound device. Fifteen residents (16.9%) were classified as having chronic dehydration (serum osmolality ≥295 mOsm/kg). Multivariate logistic regression analysis showed that chronic dehydration was associated with dementia (odds ratio (OR), 6.290; 95% confidential interval (CI), 1.270–31.154) and higher BMI (OR, 1.471; 95% CI, 1.105–1.958) but not with IVC or IVC-CI. Cognitive function and body weight of residents should be considered when establishing a strategy for preventing chronic dehydration in nursing homes.

Fluid Intake Recommendation Considering the Physiological Adaptations of Adults Over 65 Years: A Critical Review

The aim of this critical review was to clarify recommended fluid intake for older people. A literature search of published articles and guidelines on fluid intake recommendations until April 2020 was carried out using PUBMED, Scopus, Cochrane, and Google Scholar. In this review, we focused on people over 65 years old at different care levels. The results show that the mean fluid intake ranges between 311 and 2390 mL/day. However, it is difficult to know whether this corresponds to the real pattern of fluid intake, due to the variability of data collection methods. With respect to the recommendations, most international organizations do not take into consideration the physiology of ageing or the health problems associated with an older population. In conclusions, we recommend to follow the guideline of the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Food Safety Authority (EFSA). ESPEN is the only guideline which takes into account age. It is also based on EFSA recommendations. This authority takes into consideration all fluids consumed (ranging from food to fluids). If it is known that around 20% of all fluids consumed come from food, the result would effectively be that the EFSA recommends the same as the ESPEN guidelines: 1.6 L/day for females and 2.0 L/day for males. The findings could help raise the awareness of professionals in the sector with respect to the required fluid intake of the elderly and, in this way, contribute to avoiding the consequences of dehydration.

Pathophysiological mechanisms underlying a rat model of triple whammy acute kidney injury

Simultaneous administration of certain antihypertensive (renin-angiotensin system inhibitors and diuretics) and nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with a renal toxicity syndrome known as "triple whammy" acute kidney injury (TW-AKI), yet poorly characterized at the pathophysiological level, as no specific experimental model exists on which to conduct preclinical research. Herein, we generated and characterized a rat model of TW-AKI (0.7 mg/kg/day trandolapril +400 mg/kg/day ibuprofen +20 mg/kg/day furosemide). Double treatments involving the NSAID caused a subclinical acute kidney injury, as they reduced glomerular filtration rate to a significant but not sufficient extent to increase Cr_pl concentration. Only the triple treatment generated an overt AKI with increased Cr_pl provided that animals were under partial water ingestion restriction. Histological examination revealed no evidence of tissue renal injury, and no proteinuria or makers of renal damage were detected in the urine. These findings, along with a normal fractional excretion of sodium and glucose, indicated that these drug combinations produce a prerenal type of AKI. In fact, blood pressure and renal blood flow were also reduced (most markedly following the triple combination), although renal dysfunction was more pronounced than expected for the corresponding pressure drop, supporting a key pathological role of the interference with renal autoregulation mechanisms. In summary, prerenal TW-AKI only occurs when volemia is challenged (i.e., by furosemide in partially water-deprived animals) under the effects of renin-angiotensin system inhibitors and NSAIDs. This model will facilitate further pathophysiological knowledge for a better diagnosis and clinical handling of this syndrome.

Interventions to reduce dehydration related to defunctioning loop ileostomy after low anterior resection in rectal cancer: a prospective cohort study

BACKGROUND

Defunctioning loop ileostomy (DLI) in low anterior resection (LAR) in rectal cancer patients reduces the morbidity of anastomotic leakages. In our previous study, 30% of patients developed dehydration due to DLI, mostly during the first 6 weeks. This interventional study aimed to reduce these figures by establishing a surveillance programme.

METHODS

An interventional study of rectal cancer patients undergoing LAR and DLI between 2013 and 2015 was carried out. A historical study group was used as control. Stoma care nurses educated the intervention group about high-output stoma. Blood tests, including creatinine and electrolytes, were taken every second week until 8 weeks post-operatively and an additional control in case of subjective high-output stoma.

RESULTS

Eighty-seven patients underwent LAR and DLI during the study period. Twenty-one (24%) developed dehydration episodes, and nine (43%) of them required readmission. There was no difference compared to the control group, where 29% developed dehydration, and about half (52%) needed readmission (P = 0.62 and P = 0.57, respectively). However, when explicitly examining patients demonstrating symptomatic dehydration, there was a significant difference, that is 10 (11%) versus 27 (29%) (P < 0.005). Overall, the dehydrated group was older and more likely to take diuretics compared to the non-dehydrated group.

CONCLUSION

Our results indicate that reducing dehydration episodes and readmission after DLI is a challenging process. The proposed surveillance was only effective in preventing symptomatic dehydration. Subjects taking diuretics and the elderly are at risk of dehydration and should be followed cautiously.

Impending Low Intake Dehydration at Admission to A Geriatric Ward- Prevalence and Correlates in a Cross-Sectional Study

Dehydration risk increases with frailty and functional dependency, but a limited number of studies have evaluated this association in hospitalized geriatric patients. This cross-sectional study aimed to assess the prevalence and determinants of dehydration in patients admitted to the geriatric ward. Dehydration was diagnosed when calculated osmolarity was above 295 mMol/L. Logistic regression analyses (direct and stepwise backward) were used to assess determinants of impending dehydration. 358 of 416 hospitalized patients (86.1%) were included: 274 (76.5%) women, and 309 (86.4%) 75+ year-old. Dehydration was diagnosed in 209 (58.4%) cases. Significantly higher odds for impending dehydration were observed only for chronic kidney disease with trends for diabetes and procognitive medication when controlling for several health, biochemical, and nutritional parameters and medications. After adjusting for “dementia” the negative effect of “taking procognitive medications” became a significant one. Chronic kidney disease, diabetes, taking procognitive medications and hypertension were the main variables for the outcome prediction according to the stepwise backward regression analysis. This may indicate an additional benefit of reducing the risk of dehydration when using procognitive drugs in older patients with dementia.

A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications

Background: Dehydration appears prevalent, costly and associated with adverse outcomes. We sought to generate consensus on such key issues and elucidate need for further scientific enquiry. Materials and methods: A modified Delphi process combined expert opinion and evidence appraisal. Twelve relevant experts addressed dehydration's definition, objective markers and impact on physiology and outcome. Results: Fifteen consensus statements and seven research recommendations were generated. Key findings, evidenced in detail, were that there is no universally accepted definition for dehydration; hydration assessment is complex and requires combining physiological and laboratory variables; "dehydration" and "hypovolaemia" are incorrectly used interchangeably; abnormal hydration status includes relative and/or absolute abnormalities in body water and serum/plasma osmolality (pOsm); raised pOsm usually indicates dehydration; direct measurement of pOsm is the gold standard for determining dehydration; pOsm >300 and ≤280 mOsm/kg classifies a person as hyper or hypo-osmolar; outside extremes, signs of adult dehydration are subtle and unreliable; dehydration is common in hospitals and care homes and associated with poorer outcomes. Discussion: Dehydration poses risk to public health. Dehydration is under-recognized and poorly managed in hospital and community-based care. Further research is required to improve assessment and management of dehydration and the authors have made recommendations to focus academic endeavours. Key messages Dehydration assessment is a major clinical challenge due to a complex, varying pathophysiology, non-specific clinical presentations and the lack of international consensus on definition and diagnosis. Plasma osmolality represents a valuable, objective surrogate marker of hypertonic dehydration which is underutilized in clinical practice. Dehydration is prevalent within the healthcare setting and in the community, and appears associated with increased morbidity and mortality.

Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified?

BACKGROUND

Although modifying diets, by thickening liquids and modifying the texture of foods, to reduce the risk of aspiration has become central to the current management of dysphagia, the effectiveness of this intervention has been questioned. This narrative review examines, and discusses possible reasons for, the apparent discrepancy between the widespread use of modified diets in current clinical practice and the limited evidence base regarding the benefits and risks of this approach.

DISCUSSION

There is no good evidence to date that thickening liquids reduces pneumonia in dysphagia and this intervention may be associated with reduced fluid intake. Texture-modified foods may contribute to undernutrition in those with dysphagia. Modified diets worsen the quality of life of those with dysphagia, and non-compliance is common. There is substantial variability in terminology and standards for modified diets, in the recommendations of individual therapists, and in the consistency of diets prepared by healthcare staff for consumption. Although use of modified diets might appear to have a rational pathophysiological basis in dysphagia, the relationship between aspiration and pneumonia is not clear-cut. Clinical experience may be a more important determinant of everyday practice than research evidence and patient preferences. There are situations in the management of dysphagia where common sense and the necessity of intervention will clearly outweigh any lack of evidence or when application of evidence-based principles can enable good decision making despite the absence of robust evidence. Nevertheless, there is a significant discrepancy between the paucity of the evidence base supporting use of modified diets and the beliefs and practices of practitioners.

CONCLUSION

The disconnect between the limited evidence base and the widespread use of modified diets suggests the need for more careful consideration as to when modified diets might be recommended to patients. Patients (or their representatives) have a choice whether or not to accept a modified diet and must receive adequate information, about the potential risks and impact on quality of life as well as the possible benefits, to make that choice. There is an urgent need for better quality evidence regarding this intervention.

The sensitivity of the human thirst response to changes in plasma osmolality: a systematic review

BACKGROUND

Dehydration is highly prevalent and is associated with adverse cardiovascular and renal events. Clinical assessment of dehydration lacks sensitivity. Perhaps a patient's thirst can provide an accurate guide to fluid therapy. This systematic review examines the sensitivity of thirst in responding to changes in plasma osmolality in participants of any age with no condition directly effecting their sense of thirst.

METHODS

Medline and EMBASE were searched up to June 2017. Inclusion criteria were all studies reporting the plasma osmolality threshold for the sensation of thirst.

RESULTS

A total of 12 trials were included that assessed thirst intensity on a visual analogue scale, as a function of plasma osmolality (pOsm), and employed linear regression to define the thirst threshold. This included 167 participants, both healthy controls and those with a range of pathologies, with a mean age of 41 (20-78) years.The value ±95% CI for the pOsm threshold for thirst sensation was found to be 285.23 ± 1.29 mOsm/kg. Above this threshold, thirst intensity as a function of pOsm had a mean ± SEM slope of 0.54 ± 0.07 cm/mOsm/kg. The mean ± 95% CI vasopressin release threshold was very similar to that of thirst, being 284.3 ± 0.71 mOsm/kg.Heterogeneity across studies can be accounted for by subtle variation in experimental protocol and data handling.

CONCLUSION

The thresholds for thirst activation and vasopressin release lie in the middle of the normal range of plasma osmolality. Thirst increases linearly as pOsm rises. Thus, osmotically balanced fluid administered as per a patient's sensation of thirst should result in a plasma osmolality within the normal range. This work received no funding.

Hydration health literacy in the elderly

BACKGROUND

Inadequate hydration in the elderly is associated with increased morbidity and mortality. However, few studies have addressed the knowledge of elderly individuals regarding hydration in health and disease. Gaps in health literacy have been identified as a critical component in health maintenance, and promoting health literacy should improve outcomes related to hydration associated illnesses in the elderly.

METHODS

We administered an anonymous survey to community-dwelling elderly (n = 170) to gauge their hydration knowledge.

RESULTS

About 56% of respondents reported consuming >6 glasses of fluid/day, whereas 9% reported drinking ≤3 glasses. About 60% of respondents overestimated the amount of fluid loss at which moderately severe dehydration symptoms occur, and 60% did not know fever can cause dehydration. Roughly 1/3 were not aware that fluid overload occurs in heart failure (35%) or kidney failure (32%). A majority of respondents were not aware that improper hydration or changes in hydration status can result in confusion, seizures, or death.

CONCLUSIONS

Overall, our study demonstrated that there were significant deficiencies in hydration health literacy among elderly. Appropriate education and attention to hydration may improve quality of life, reduce hospitalizations and the economic burden related to hydration-associated morbidity and mortality.

Fatty Acids, Antioxidants and Physical Activity in Brain Aging

Polyunsaturated fatty acids and antioxidants are important mediators in the central nervous system. Lipid derivatives may control the production of proinflammatory agents and regulate NF-κB activity, microglial activation, and fatty acid oxidation; on the other hand, antioxidants, such as glutathione and ascorbate, have been shown to signal through transmitter receptors and protect against acute and chronic oxidative stress, modulating the activity of different signaling pathways. Several authors have investigated the role of these nutrients in the brains of the young and the aged in degenerative diseases such as Alzheimer’s and Parkinson’s, and during brain aging due to adiposity- and physical inactivity-mediated metabolic disturbances, chronic inflammation, and oxidative stress. Through a literature review, we aimed to highlight recent data on the role of adiposity, fatty acids, antioxidants, and physical inactivity in the pathophysiology of the brain and in the molecular mechanisms of senescence. Data indicate the complexity and necessity of endogenous/dietary antioxidants for the maintenance of redox status and the control of neuroglial signaling under stress. Recent studies also indicate that omega-3 and -6 fatty acids act in a competitive manner to generate mediators for energy metabolism, influencing feeding behavior, neural plasticity, and memory during aging. Finding pharmacological or dietary resources that mitigate or prevent neurodegenerative affections continues to be a great challenge and requires additional effort from researchers, clinicians, and nutritionists in the field.

Dysnatremia in Relation to Frailty and Age in Community-dwelling Adults in the National Health and Nutrition Examination Survey

Background

Frailty represents an age-related state of increased risk of adverse health outcomes, reflecting some combination of increased damage and compromised repair processes. Our objectives were to establish whether frailty is associated with dysnatremia (a deviation of serum sodium from normal values), to determine whether frailty explains the previously established association between age and dysnatremia and to assay the impact of each on mortality.

Methods

The relationship between age, frailty, and dysnatremia was investigated across the adult life course in 8,911 respondents from the 2003-2004 and 2005-2006 cross-sectional National Health and Nutrition Examination Survey, on whom both laboratory and mortality data were available. A frailty index (FI) was calculated for each respondent and related to dysnatremia (serum sodium values outside a 136-144 mmol/L reference range).

Results

Dysnatremia was significantly related to both age and frailty; as the degree of frailty increased, so did the proportion with dysnatremia, for example, from 4.1% in those with FI less than 0.10, to 12.4% in those with FI 0.40 or more; p less than .001. Adjusted for frailty, the relationship between age and dysnatremia was no longer significant. In the age- and sex-adjusted Cox models, both frailty (hazard ratio [HR]: 1.05; 95% confidence interval [CI]: 1.04-1.05 for every 0.01 increase in FI) and dysnatremia (HR: 1.85; 95% CI: 1.51-2.26) were significant predictors of mortality; when hyponatremia was separated from hypernatremia in the Cox models, hypernatremia wasn't significant, but only 41 participants were identified as hypernatremic.

Conclusion

Increasing frailty is associated with dysnatremia and confounds the association between age and dysnatremia.

Aging human body: changes in bone, muscle and body fat with consequent changes in nutrient intake

Aging affects almost all physiological processes, but changes in body composition and body phenotype are most observable. In this review, we focus on these changes, including loss of bone and muscle and increase in body fat or redistribution of the latter, possibly leading to osteosarcopenic obesity syndrome. We also address low-grade chronic inflammation, prevalent in aging adults and a cause of many disorders including those associated with body composition. Changes in dietary intake and nutritional requirements of older individuals, that all may lead to some disturbances on tissue and organ levels, are discussed as well. Finally, we discuss the hormonal changes in the aging body, considering each of the tissues, bone, muscle and fat as separate endocrine organs, but yet in the continuous interface and communication with each other. Although there are still many unanswered questions in this field, this review will enable the readers to better understand the aging human body and measures needing to be implemented toward reducing impaired health and disability in older individuals.

Beverage Consumption Habits among the European Population: Association with Total Water and Energy Intakes

BACKGROUND

Fluid and water intake have received limited attention in epidemiological studies. The aim of this study was to compare the average daily consumption of foods and beverages in adults of selective samples of the European Union (EU) population in order to understand the contribution of these to the total water intake (TWI), evaluate if the EU adult population consumes adequate amounts of total water (TW) according to the current guidelines, and to illustrate the real water intake in Europe.

METHODS

Three national European dietary surveys have been selected: Spain used the Anthropometry, Intake, and Energy Balance Study (ANIBES) population database, Italy analyzed data from the Italian National Food Consumption Survey (INRAN-SCAI 2005-06), and French data came from the NutriNet-Santé database. Mean daily consumption was used to compare between individuals. TWI was compared with European Food Safety Authority (EFSA) reference values for adult men and women.

RESULTS

On average, in Spain, TWI was 1.7 L (SE 22.9) for men and 1.6 L (SE 19.4) for women; Italy recorded 1.7 L (SE 16.9) for men and 1.7 L (SE 14.1) for women; and France recorded 2.3 L (SE 4.7) for men and 2.1 L (SE 2.4) for women. With the exception of women in France, neither men nor women consumed sufficient amounts of water according to EFSA reference values.

CONCLUSIONS

This study highlights the need to formulate appropriate health and nutrition policies to increase TWI in the EU population. The future of beverage intake assessment requires the use of new instruments, techniques, and the application of the new available technologies.

Water and Beverage Consumption: Analysis of the Australian 2011-2012 National Nutrition and Physical Activity Survey

Background: Water consumption as a vital component of the human diet is under-researched in dietary surveys and nutrition studies. Aim: To assess total water and fluid intakes and examine demographic, anthropometric, and dietary factors associated with water consumption in the Australian population. Methods: Dietary intake data from the 2011 to 2012 National Nutrition and Physical Activity Survey were used. Usual water, fluid and food and nutrient intakes were estimated from two days of dietary recalls. Total water includes plain drinking water and moisture from all food and beverage sources; total fluids include plain drinking water and other beverages, but not food moisture. Results: The mean (SD) daily total water intakes for children and adolescents aged 2–18 years were 1.7 (0.6) L for males and 1.5 (0.4) L for females, and for adults aged 19 years and over were 2.6 (0.9) L for males and 2.3 (0.7) L for females. The majority of the population failed to meet the Adequate Intake (AI) values for total water intake (82%) and total fluids intake (78%) with the elderly at highest risk (90%–95%). The contributions of plain drinking water, other beverages and food moisture to total water intake were 44%, 27%, and 29%, respectively, among children and adolescents, and 37%, 37% and 25% among adults. The main sources of other beverages were full-fat plain milk and regular soft drinks for children and adolescents, and tea, coffee, and alcoholic drinks for adults. For adults, higher total water intake was associated with lower percent energy from fat, saturated fat, and free sugars, lower sodium and energy-dense nutrient poor food intakes but higher dietary fibre, fruit, vegetable, caffeine, and alcohol intakes. No associations were found between total water consumption and body mass index (BMI) for adults and BMI z-score for children and adolescents. Conclusion: Reported water consumption was below recommendations. Higher water intakes were suggestive of better diet quality.

Dehydration and Cognition in Geriatrics: A Hydromolecular Hypothesis

Dehydration is one of the ten most frequent diagnoses responsible for the hospital admission of elderly in the United States. It is associated with increased mortality, morbidity and an estimated cost of 1.14 billion per year (Xiao et al., 2004; Schlanger et al., 2010; Pretorius et al., 2013; Frangeskou et al., 2015). Older individuals are predisposed to dehydration encephalopathy as a result of decreased total body water (TBW) and diminished sensation of thirst. We hypothesize that thirst blunting in older individuals is the result of a defective microRNA-6842-3p failing to silence the expression of the vesicular GABA transporters (VGAT) and alpha 7 cholinergic nicotinic receptors in the subfornical organ (SFO) of the hypothalamus. We hypothesize further that resultant dehydration facilitates protein misfolding and aggregation, predisposing to neurocognitive disorders. We completed a search of predicted microRNA targets, utilizing the public domain tool miRDB and found that microRNA-6842-3p modulates the SLC6A1 and CHRNA7 genes both of which were previously hypothesized to inhibit the thirst sensation by their action on SFO. The primary aim of this article is to answer two questions: Can prevention and correction of dehydration in elderly lower age-related cognitive deterioration? Can exosomal miR-6842 in the peripheral blood predict dehydration encephalopathy in elderly?

Beverage Consumption Habits and Association with Total Water and Energy Intakes in the Spanish Population: Findings of the ANIBES Study

Background: Inadequate hydration is a public health issue that imposes a significant economic burden. In Spain, data of total water intake (TWI) are scarce. There is a clear need for a national study that quantifies water and beverage intakes and explores associations between the types of beverages and energy intakes. Methods: The Anthropometry, Intake and Energy Balance Study ANIBES is a national survey of diet and nutrition conducted among a representative sample of 2285 healthy participants aged 9–75 years in Spain. Food and beverage intakes were assessed in a food diary over three days. Day and time of beverage consumption were also recorded. Results: On average, TWI was 1.7 L (SE 21.2) for men and 1.6 L (SE 18.9) for women. More than 75% of participants had inadequate TWI, according to European Food Safety Authority (EFSA) recommendations. Mean total energy intake (EI) was 1810 kcal/day (SE 11.1), of which 12% was provided by beverages. Water was the most consumed beverage, followed by milk. The contribution of alcoholic drinks to the EI was near 3%. For caloric soft drinks, a relatively low contribution to the EI was obtained, only 2%. Of eight different types of beverages, the variety score was positively correlated with TWI (r = 0.39) and EI (r = 0.23), suggesting that beverage variety is an indicator of higher consumption of food and drinks. Conclusions: The present study demonstrates that well-conducted surveys such as the ANIBES study have the potential to yield rich contextual value data that can emphasize the need to undertake appropriate health and nutrition policies to increase the total water intake at the population level promoting a healthy Mediterranean hydration pattern.