Hypernatremic dehydration in nursing home patients: an indicator of neglect

Enteral free water vs. parenteral dextrose 5% in water for the treatment of hypernatremia in the intensive care unit: a retrospective cohort study from a mixed ICU

PURPOSE

Effective treatment options for patients with hypernatremia are limited. Free water administration (parenterally or enterally) is the mainstay of treatment but the impact of each strategy on lowering serum sodium (Na) is not known. The purpose of the study was thus to assess the effectiveness of enteral free water vs. parenteral dextrose 5% in water (D5W) in treating ICU-acquired hypernatremia.

METHODS

An electronic medical record-based, retrospective cohort study was conducted in a 30-bed mixed medical-surgical intensive care unit (ICU) in Japan. All adult patients admitted to the ICU from August 2017 to July 2021 were reviewed. After a 2-step exclusion, patients who stayed in the ICU ≥ 24 h and received either or both treatments for ICU-acquired hypernatremia (Na ≥ 145 mEq/L) constituted the study cohort. The primary outcome was a change in serum Na during the 24 h before treatment each day (ΔNa); the secondary outcomes were gastrointestinal complications, serum glucose levels, ICU/hospital mortality, ICU/hospital length of stay, and the duration of mechanical ventilation. Repeated measurements on each patient were addressed using a generalized estimated equation (GEE) for multiple linear regression analysis. Analysis was conducted with R version 4.0.3.

RESULTS

In total, 256/6596 (131: D5W, 125: enteral free water) patients were analyzed. Median treatment lasted 6 days [3-17] for the D5W group vs 7 days [3-14] for the enteral free water group with a total median daily treatment volume of 799 [IQR 299-1221] mL vs. 400 [IQR 262-573] mL. GEE multiple linear regression analysis showed an estimated mean ΔNa per liter of treatment fluid of - 2.25 [95% CI - 2.76 to - 1.74] mEq/L per liter of parenteral D5W vs. - 1.91 mEq decrease [95% CI - 2.75 to - 1.07] per liter of enteral free water. Hydrochlorothiazide was the only medication associated with a statistically significant negative ΔNa by- 0.89 [- 1.57 to - 0.21] mEq/L. There were no significant inter-group differences for secondary outcomes.

CONCLUSIONS

These results suggest that both enteral free water and parenteral D5W are effective for treating ICU-acquired hypernatremia. Parenteral D5W was slightly more effective than enteral free water to lower serum Na levels in patients with ICU-acquired hypernatremia.

TRIAL REGISTRATION

Not applicable.

Restoration of dysnatremia and acute kidney injury benefits outcomes of acute geriatric inpatients

Dysnatremia and dyskalemia are common problems in acutely hospitalized elderly patients. These disorders are associated with an increased risk of mortality and functional complications that often occur concomitantly with acute kidney injury in addition to multiple comorbidities. In a single-center prospective observational study, we recruited 401 acute geriatric inpatients. In-hospital outcomes included all-cause mortality, length of stay, and changes in functional status as determined by the Activities of Daily Living (ADL) scale, Eastern Cooperative Oncology Group (ECOG) performance, and Clinical Frailty Scale (CFS). The prevalence of dysnatremia alone, dyskalemia alone, and dysnatremia plus dyskalemia during initial hospitalization were 28.4%, 14.7% and 32.4%, respectively. Patients with electrolyte imbalance exhibited higher mortality rates and longer hospital stays than those without electrolyte imbalance. Those with initial dysnatremia, or dysnatremia plus dyskalemia were associated with worse ADL scores, ECOG performance and CFS scores at discharge. Subgroup analyses showed that resolution of dysnatremia was related to reduced mortality risk and improved CFS score, whereas recovery of renal function was associated with decreased mortality and better ECOG and CFS ratings. Our data suggest that restoration of initial dysnatremia and acute kidney injury during acute geriatric care may benefit in-hospital survival and functional status at discharge.

Suboptimal management of hypernatraemia in acute medical admissions

BACKGROUND

Hypernatraemia arises commonly in acute general medical admissions. Affected patients have a guarded prognosis with high rates of morbidity and mortality. Age-related physiology and physical/cognitive barriers to accessing water predispose older patients to developing hypernatraemia. This study sought to perform a descriptive retrospective review of hypernatraemic patients admitted under acute general medicine teams.

METHODS

A retrospective cross-sectional study of a sample of acute medical in-patients with serum[sodium]>145 mmol/L was conducted. Patients were exclusively older(>69 years) and admitted from Nursing homes (NH)(41%) and non-NH pathways(59%). A comparison of management of NH /non-NH patients including clinical presentation, comorbidities, laboratory values, [sodium] monitoring, intravenous fluid regimes and patient outcomes was performed.

RESULTS

In total, 102 consecutive patients (males, n=69(67.6%)) were included. Dementia and reduced mobility were more common in NH residents and admission serum [Sodium] higher (148 vs 142 mmol/L/p=0.003). Monitoring was inadequate: no routine bloods within the first 12h in >80% of patients in both groups. No patient had calculated free water deficit documented. More NH patients received correct fluid management (60% vs 33%/p%0.015). Incorrect fluid regimes occurred in both groups (38% vs 58%/p=0.070). Length of stay in discharged patients was lower in NH, (8(4-20) vs 20.5(9.8-49.3 days)/p=0.003). Time to death for NH residents was shorter (9(5.5-11.5) vs 16 (10.25-23.5) days/p=0.011).

CONCLUSION

This study highlights suboptimal management of hypernatraemia. Implementation of hypernatraemia guidelines for general medical older inpatients are clearly required with mechanisms to confirm adherence. Health care workers require further education on diagnostic challenges of dehydration in older people and the importance of maintaining adequate hydration.

What Serum Sodium Concentration Is Suggestive for Underhydration in Geriatric Patients?

Dehydration is a concern among aging populations and can result in hospitalization and other adverse outcomes. There is a need to establish simple measures that can help in detecting low-intake dehydration (underhydration) in geriatric patients. The predictive performance of sodium, urea, glucose, and potassium to discriminate between patients with and without underhydration was evaluated using receiver-operating characteristic (ROC) curve analysis of data collected during the cross-sectional study of patients admitted to the geriatric ward. A total of 358 participants, for whom osmolarity could be calculated with the Khajuria and Krahn equation, were recruited to the study. Impending underhydration (osmolarity > 295 mmol/L) was diagnosed in 58.4% of cases. Serum sodium, urea, fasting glucose, and potassium (individual components of the equation) were significantly higher in dehydrated participants. The largest ROC area of 0.88 was obtained for sodium, and the value 140 mMol/L was found as the best cut-off value, with the highest sensitivity (0.80; 95% CI: 0.74–0.86) and specificity (0.83; 95% CI: 0.75–0.88) for prediction of underhydration. The ROC areas of urea, glucose, and potassium were significantly lower. Serum sodium equal to 140 mmol/L or higher appeared to be suggestive of impending underhydration in geriatric patients. This could be considered as the first-step screening procedure for detecting underhydration in older adults in general practice, especially when limited resources restrict the possibility of more in-depth biochemical assessments.

Impact of age on the seasonal prevalence of hypernatremia in the emergency department: a single-center study

Background

Hypernatremia is one of the most commonly encountered electrolyte disorders in the emergency department (ED). Few studies have reported the seasonal fluctuations of the prevalence of hypernatremia with conflicting results. We investigated the seasonal prevalence of hypernatremia in an emergency department in Japan.

Methods

A total of 12,598 patients presented to the ED between January 2015 and December 2017 were reviewed. The adult group aged between 18 and 64 years old consisted of 5427 patients and the elderly group aged over 65 years consisted of 7171 patients. Information collected included age, sex, serum sodium, and serum creatinine. Hypernatremia was defined as a serum sodium leve1 > 145 mEq/L, and moderate to severe hypernatremia was defined as a serum sodium level ≥ 150 mEq/L.

Results

The prevalence of hypernatremia was significantly higher in the elderly group than in the adult group (2.6% vs. 0.7%; p < 0.001). Similarly, the prevalence of moderate to severe hypernatremia was significantly higher in the elderly group than in the adult group (1.0% vs. 0.1%; p < 0.001). The prevalence of hypernatremia and moderate to severe hypernatremia was significantly higher in the elderly group than in the adult group in all seasons. In the elderly group, the seasonal prevalence of moderate to severe hypernatremia was significantly higher during the winter. Also, there was a correlation between weather temperature and the prevalence of moderate to severe hypernatremia in the elderly group (r = − 0.34, p = 0.04).

Conclusions

Hypernatremia is prevalent in the elderly and the prevalence is highest during the winter. Special attention should be paid in the elderly patients to prevent hypernatremia especially in the winter.

Osmotic stress and mortality in elderly patients with kidney failure: a retrospective study

Purpose

Water balance disorders are associated with a high risk of death in elderly patients. The role of osmotic stress intensity and its direction toward hypo- or hypernatremia is a matter of controversy regarding patients’ survival. The aims of this study were, first, to measure the frequency of cellular hydration disorders in patients over 75 years old hospitalized in nephrology department for reversible acute renal failure, and second, to compare the impact of hyperhydration and hypohydration on the risk of death at 6 months.

Patients and methods

We retrospectively studied the data of 279 patients with chronic kidney disease (CKD), aged 75 years or older, with pre-renal azotemia who experienced dysnatremia. We classified them according to natremia levels and compared their outcome in univariate and multivariate analysis.

Results

The patients were on average 83.2±5.4 years old. Among them, 128 were normonatremic, 82 were hyponatremic and 69 were hypernatremic. Osmotic stress intensity appreciated by the variation rate of natremia did not differ significantly between hyper- and hyponatremic patients. Patients had CKD stage 3B and 4 with acute kidney injury (AKI) of different severities. We observed that only hypernatremia was linked to death in the first 6 months following hospital discharge.

Conclusion

Hypernatremia is a strong predictor of fatal outcome in elderly patients suffering from chronic kidney impairment and referred for pre-renal azotemia.

Neurocognitive Disorders and Dehydration in Older Patients: Clinical Experience Supports the Hydromolecular Hypothesis of Dementia

Abnormalities of water homeostasis can be early expressions of neuronal dysfunction, brain atrophy, chronic cerebrovasculopathy and neurodegenerative disease. The aim of this study was to analyze the serum osmolality of subjects with cognitive impairment. One thousand and ninety-one consecutive patients attending the Alzheimer’s Evaluation Unit were evaluated with the Mini-Mental State Examination (MMSE), 21-Item Hamilton Depression Rating Scale (HDRS-21), Activities of Daily Living (ADL), Instrumental-ADL (IADL), Mini Nutritional Assessment (MNA), Exton-Smith Scale (ESS), and Cumulative Illness Rating Scale (CIRS). For each patient, the equation for serum osmolality developed by Khajuria and Krahn was applied. Five hundred and seventy-one patients had cognitive decline and/or depression mood (CD-DM) and 520 did not have CD-DM (control group). Patients with CD-DM were less likely to be male (p < 0.001), and were more likely to be older (p < 0.001), have a significant clear cognitive impairment (MMSE: p < 0.001), show the presence of a depressive mood (HDRS-21: p < 0.001) and have major impairments in ADL (p < 0.001), IADL (p < 0.001), MNA (p < 0.001), and ESS (p < 0.001), compared to the control group. CD-DM patients had a higher electrolyte concentration (Na⁺: p < 0.001; K⁺: p < 0.001; Cl⁻: p < 0.001), risk of dehydration (osmolality p < 0.001), and kidney damage (eGFR: p = 0.021), than the control group. Alzheimer’s disease (AD) patients showed a major risk for current dehydration (p ≤ 0.001), and dehydration was associated with the risk of developing a type of dementia, like AD or vascular dementia (VaD) (OR = 2.016, p < 0.001). In the multivariate analysis, the presence of dehydration state was associated with ADL (p < 0.001) and IADL (p < 0.001), but independently associated with age (r² = 0.0046, p = 0.77), ESS (r² = 0.0052, p = 0.54) and MNA (r² = 0.0004, p = 0.48). Moreover, younger patients with dementia were significantly more dehydrated than patients without dementia (65–75 years, p = 0.001; 76–85 years, p = 0.001; ≥86 years, p = 0.293). The hydromolecular hypothesis intends to explain the relationship between dehydration and cognitive impairment in older patients as the result of protein misfolding and aggregation, in the presence of a low interstitial fluid volume, which is a defect of the microcirculation. Defective proteins were shown to impair the amount of information in brain biomolecular mechanisms, with consequent neuronal and synaptic damage.

Hospital-Associated Hypernatremia Spectrum and Clinical Outcomes in an Unselected Cohort

BACKGROUND

Although hypernatremia is associated with adverse outcomes, most studies examined selected populations.

METHODS

Discharge data of 19,072 unselected hospitalized adults were analyzed. The crude relationship between serum sodium [Na⁺] and mortality defined hypernatremia as serum [Na⁺] >142 mEq/L. Patients with community-acquired hypernatremia or hospital-acquired hypernatremia were compared with normonatremic patients (admission [Na⁺] 138-142 mEq/L) regarding in-hospital mortality, length of stay, and discharge disposition. Patients with community-acquired hypernatremia whose hypernatremia worsened during hospitalization were compared with those without aggravation.

RESULTS

Community-acquired hypernatremia occurred in 21% of hospitalized patients and was associated with an adjusted odds ratio (OR) of 1.67 (95% confidence interval [CI], 1.38-2.01) for in-hospital mortality and 1.44 (95% CI, 1.32-1.56) for discharge to a short-/long-term care facility and an adjusted 10% (95% CI, 7-13) increase in length of stay. Hospital-acquired hypernatremia developed in 25.9% of hospitalized patients and was associated with an adjusted OR of 3.17 (95% CI, 2.45-4.09) for in-hospital mortality and 1.45 (95% CI, 1.32-1.59) for discharge to a facility, and an adjusted 49% (95% CI, 44-53) increase in length of stay. Hospital-aggravated hypernatremia developed in 11.7% of patients with community-acquired hypernatremia and was associated with greater risk of in-hospital mortality (adjusted OR, 1.84; 95% CI, 1.32-2.56) and discharge to a facility (adjusted OR, 2.14; 95% CI, 1.71-2.69), and an adjusted 16% (95% CI, 7-27) increase in length of stay.

CONCLUSIONS

The hypernatremia spectrum in unselected hospitalized patients is independently associated with increased in-hospital mortality and heightened resource consumption.

Methods of Assessment of Hydration Status and their Usefulness in Detecting Dehydration in the Elderly

Assessment of hydration status is complex and difficult to achieve. Few assessment methods have been validated to accurately measure the fluid compartments in the body, but they have little application in practice. Different techniques have been developed to determine hydration status for the use in clinical settings, but their diagnostic accuracy remains questionable. Since many experts argue that there is no 'gold-standard' technique and one can never be achieved, this paper describes both, the benefits and limitations of the available methods and their usability in assessing hydration status of the elderly.

Clinical assessments and care interventions to promote oral hydration amongst older patients: a narrative systematic review

BACKGROUND

Older patients in hospital may be unable to maintain hydration by drinking, leading to intravenous fluid replacement, complications and a longer length of stay. We undertook a systematic review to describe clinical assessment tools which identify patients at risk of insufficient oral fluid intake and the impact of simple interventions to promote drinking, in hospital and care home settings.

METHOD

MEDLINE, CINAHL, and EMBASE databases and two internet search engines (Google and Google Scholar) were examined. Articles were included when the main focus was use of a hydration/dehydration risk assessment in an adult population with/without a care intervention to promote oral hydration in hospitals or care homes. Reviews which used findings to develop new assessments were also included. Single case reports, laboratory results only, single technology assessments or non-oral fluid replacement in patients who were already dehydrated were excluded. Interventions where nutritional intake was the primary focus with a hydration component were also excluded. Identified articles were screened for relevance and quality before a narrative synthesis. No statistical analysis was planned.

RESULTS

From 3973 citations, 23 articles were included. Rather than prevention of poor oral intake, most focused upon identification of patients already in negative fluid balance using information from the history, patient inspection and urinalysis. Nine formal hydration assessments were identified, five of which had an accompanying intervention/ care protocol, and there were no RCT or large observational studies. Interventions to provide extra opportunities to drink such as prompts, preference elicitation and routine beverage carts appeared to support hydration maintenance, further research is required. Despite a lack of knowledge of fluid requirements and dehydration risk factors amongst staff, there was no strong evidence that increasing awareness alone would be beneficial for patients.

CONCLUSION

Despite descriptions of features associated with dehydration, there is insufficient evidence to recommend a specific clinical assessment which could identify older persons at risk of poor oral fluid intake; however there is evidence to support simple care interventions which promote drinking particularly for individuals with cognitive impairment.

TRIAL REGISTRATION

PROSPERO 2014:CRD42014015178.

Review on Mechanisms, Importance of Homeostasis and Fluid Imbalances in the Elderly

Water is considered an essential nutrient, but very often is overlooked in favour of nutrition. Due to age related changes, older people are more vulnerable to both, dehydration and overhydration. This article describes the principles of water homeostasis and provides a description of common age-related physiological changes related to water balance. Fluid homeostasis largely depends on osmo- and baro-receptors that respectively react to changes in osmolality and blood pressure, water-regulating hormone release, the subsequent response of kidneys to the hormonal stimulation and activation of thirst. These mechanisms diminish with age and put elderly at risk of dehydration. All involved in a care for the elderly should be informed and become vigilant to prevent dehydration from occurring.

Incidence, severity and prognosis associated with hypernatremia in dogs and cats

Background

Hypernatremia has been associated with substantial morbidity and death in human patients. The incidence and importance of hypernatremia in dogs and cats has not been determined.

Hypothesis/Objectives

To describe the incidence of and prognosis associated with hypernatremia in dogs and cats at a university teaching hospital.

Animals

A total of 16,691 dogs and 4,211 cats with measured blood or serum sodium concentration.

Methods

Retrospective study. Medical records of animals with a blood or serum sodium concentration measured during a 60‐month period were reviewed to determine the severity of hypernatremia and its associated case fatality rate. Cases with moderate (11–15 mmol/L above the reference range) or severe hypernatremia (≥16 mmol/L above the reference range) were further reviewed.

Results

A total of 957 dogs (5.7%) and 338 cats (8.0%) were diagnosed with hypernatremia. Case fatality rates of dogs and cats with hypernatremia was 20.6 and 28.1%, respectively compared to 4.4 and 4.5% with a normal blood or serum sodium concentration (P < .0001). The magnitude of hypernatremia was linearly associated with a higher case fatality rate (P < .0001). Hypernatremia was associated with a higher case fatality rate than hyponatremia. Among the animals with moderate or severe hypernatremia, 50% of dogs and 38.5% of cats presented with community‐acquired hypernatremia, and 50% of dogs and 61.5% of cats developed hospital‐acquired hypernatremia.

Conclusions and clinical importance

Hypernatremia was found infrequently in this population but was associated with increased case fatality rates in dogs and cats. Presence and severity of hypernatremia might be useful as a prognostic indicator.

Hypermagnesemia is a strong independent risk factor for mortality in critically ill patients: results from a cross-sectional study

BACKGROUND

Patients with electrolyte imbalances or disorders have a high risk of mortality. It is unknown if this finding from sodium or potassium disorders extends to alterations of magnesium levels.

METHODS AND PATIENTS

In this cross-sectional analysis, all emergency room patients between 2010 and 2011 at the Inselspital Bern, Switzerland, were included. A multivariable logistic regression model was performed to assess the association between magnesium levels and in-hospital mortality up to 28days.

RESULTS

A total of 22,239 subjects were screened for the study. A total of 5339 patients had plasma magnesium concentrations measured at hospital admission and were included into the analysis. A total of 6.3% of the 352 patients with hypomagnesemia and 36.9% of the 151 patients with hypermagnesemia died. In a multivariate Cox regression model hypermagnesemia (HR 11.6, p<0.001) was a strong independent risk factor for mortality. In these patients diuretic therapy revealed to be protective (HR 0.5, p=0.007). Hypomagnesemia was not associated with mortality (p>0.05). Age was an independent risk factor for mortality (both p<0.001).

CONCLUSION

The study does demonstrate a possible association between hypermagnesemia measured upon admission in the emergency department, and early in-hospital mortality.

Dehydration in the Elderly: A Review Focused on Economic Burden

BACKGROUND

Dehydration is the most common fluid and electrolyte problem among elderly patients. It is reported to be widely prevalent and costly to individuals and to the health care system. The purpose of this review is to summarize the literature on the economic burden of dehydration in the elderly.

METHOD

A comprehensive search of several databases from database inception to November 2013, only in English language, was conducted. The databases included Pubmed and ISI Web of Science. The search terms «dehydration» / "hyponaremia" / "hypernatremia" AND «cost» AND «elderly» were used to search for comparative studies of the economic burden of dehydration. A total of 15 papers were identified.

RESULTS

Dehydration in the elderly is an independent factor of higher health care expenditures. It is directly associated with an increase in hospital mortality, as well as with an increase in the utilization of ICU, short and long term care facilities, readmission rates and hospital resources, especially among those with moderate to severe hyponatremia.

CONCLUSIONS

Dehydration represents a potential target for intervention to reduce healthcare expenditures and improve patients' quality of life.

Hypernatremia in the geriatric population

Hypernatremia in the geriatric population is a common disorder associated with significant morbidity and mortality. Older people are predisposed to developing hypernatremia because of age-related physiologic changes such as decreased thirst drive, impaired urinary concentrating ability, and reduced total body water. Medications may exacerbate this predisposition. Hypernatremia and dehydration occurring in nursing homes are considered indicators of neglect that warrant reporting, but there are other nonavoidable causes of hypernatremia, and consideration at time of presentation is essential to prevent delay in diagnosis and management. We describe a case illustrating the importance of the consideration of alternate explanations for hypernatremia in a nursing home resident, followed by a review of hypernatremia in the elderly population, to underscore that neglect is the etiology of exclusion after alternatives have been considered.

Medical and laboratory indicators of elder abuse and neglect

Elder abuse and neglect are highly prevalent but woefully underdetected and underreported. The presentation is rarely clear and requires the piecing together of clues that create a mosaic of the full picture. More research needed to better characterize findings that, when identified, can contribute to certainty in cases of suspected abuse. Medical and laboratory data can be helpful in the successful determination of abuse and neglect.

Electrolyte disorders and in-hospital mortality during prolonged heat periods: a cross-sectional analysis

Background

Heat periods during recent years were associated with excess hospitalization and mortality rates, especially in the elderly. We intended to study whether prolonged warmth/heat periods are associated with an increased prevalence of disorders of serum sodium and potassium and an increased hospital mortality.

Methods

In this cross-sectional analysis all patients admitted to the Department of Emergency Medicine of a large tertiary care facility between January 2009 and December 2010 with measurements of serum sodium were included. Demographic data along with detailed data on diuretic medication, length of hospital stay and hospital mortality were obtained for all patients. Data on daily temperatures (maximum, mean, minimum) and humidity were retrieved by Meteo Swiss.

Results

A total of 22.239 patients were included in the study. 5 periods with a temperature exceeding 25°C for 3 to 5 days were noticed and 2 periods with temperatures exceeding 25°C for more than 5 days were noted. Additionally, 2 periods with 3 to 5 days with daily temperatures exceeding 30°C were noted during the study period. We found a significantly increased prevalence of hyponatremia during heat periods. However, in the Cox regression analysis, prolonged heat was not associated with the prevalence of disorders of serum sodium or potassium. Admission during a heat period was an independent predictor for hospital mortality.

Conclusions

Although we found an increased prevalence of hyponatremia during heat periods, no convincing connection could be found for hypernatremia or disorders of serum potassium.

Undercorrection of hypernatremia is frequent and associated with mortality

Background

About 1% of patients admitted to the Emergency Department (ED) have hypernatremia, a condition associated with a mortality rate of 20 to 60%. Management recommendations originate from intensive care unit studies, in which patients and medical diseases differ from those in ED.

Methods

We retrospectively studied clinical characteristics, treatments, and outcomes of severely hypernatremic patients in the ED and risk factors associated with death occurrence during hospitalization.

Results

During 2010, 85 cases of severe hypernatremia ≥150 mmol/l were admitted to ED. Hypernatremia occurred in frail patients: mean age 79.7 years, 55% institutionalized, 28% with dementia.

Twenty four percent of patients died during hospitalization. Male gender and low mean blood pressure (MBP) were independently associated with death, as well as slow natremia correction speed, but not the severity of hyperosmolarity at admission. Infusion solute was inappropriate for 45% of patients with MBP <70 mmHg who received hypotonic solutes and 22% of patients with MBP ≥70 mmHg who received isotonic solutes or were not perfused.

Conclusions

This is the first study assessing outcome of hypernatremic patients in the ED according to the treatment provided. It appears that not only a too quick, but also a too slow correction speed is associated with an increased risk of death regardless of initial natremia. Medical management of hypernatremic patients must be improved regarding evaluation and treatment.

Preoperative hypernatremia predicts increased perioperative morbidity and mortality

BACKGROUND

The prognostic implications of preoperative hypernatremia are unknown. We sought to determine whether preoperative hypernatremia is a predictor of 30-day perioperative morbidity and mortality.

METHODS

We conducted a cohort study using the American College of Surgeons-National Surgical Quality Improvement Program and identified 908,869 adult patients undergoing major surgery from approximately 300 hospitals from the years 2005 to 2010. We followed the patients for 30-day perioperative outcomes, which included death, major coronary events, wound infections, pneumonia, and venous thromboembolism. Multivariable logistic regression was used to estimate the odds of 30-day perioperative outcomes.

RESULTS

The 20,029 patients (2.2%) with preoperative hypernatremia (>144 mmol/L) were compared with the 888,840 patients with a normal baseline sodium (135-144 mmol/L). Hypernatremia was associated with a higher odds for 30-day mortality (5.2% vs 1.3%; adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.33-1.56), and this finding was consistent in all subgroups. The odds increased according to the severity of hypernatremia (P < .001 for pairwise comparison for mild [145-148 mmol/L] vs severe [>148 mmol/L] categories). Furthermore, hypernatremia was associated with a greater odds for perioperative major coronary events (1.6% vs 0.7%; aOR, 1.16; 95% CI, 1.03-1.32), pneumonia (3.4% vs 1.5%; aOR, 1.23; 95% CI, 1.13-1.34), and venous thromboembolism (1.8% vs 0.9%; OR, 1.28; 95% CI, 1.14-1.42).

CONCLUSION

Preoperative hypernatremia is associated with increased perioperative 30-day morbidity and mortality.

Rising serum sodium levels are associated with a concurrent development of metabolic alkalosis in critically ill patients

PURPOSE

Changes in electrolyte homeostasis are important causes of acid-base disorders. While the effects of chloride are well studied, only little is known of the potential contributions of sodium to metabolic acid-base state. Thus, we investigated the effects of intensive care unit (ICU)-acquired hypernatremia on acid-base state.

METHODS

We included critically ill patients who developed hypernatremia, defined as a serum sodium concentration exceeding 149 mmol/L, after ICU admission in this retrospective study. Data on electrolyte and acid-base state in all included patients were gathered in order to analyze the effects of hypernatremia on metabolic acid-base state by use of the physical-chemical approach.

RESULTS

A total of 51 patients were included in the study. The time of rising serum sodium and hypernatremia was accompanied by metabolic alkalosis. A transient increase in total base excess (standard base excess from 0.1 to 5.5 mmol/L) paralleled by a transient increase in the base excess due to sodium (base excess sodium from 0.7 to 4.1 mmol/L) could be observed. The other determinants of metabolic acid-base state remained stable. The increase in base excess was accompanied by a slight increase in overall pH (from 7.392 to 7.429, standard base excess from 0.1 to 5.5 mmol/L).

CONCLUSIONS

Hypernatremia is accompanied by metabolic alkalosis and an increase in pH. Given the high prevalence of hypernatremia, especially in critically ill patients, hypernatremic alkalosis should be part of the differential diagnosis of metabolic acid-base disorders.

Characteristics, symptoms, and outcome of severe dysnatremias present on hospital admission

OBJECTIVE

Dysnatremias are common in critically ill patients and associated with adverse outcomes, but their incidence, nature, and treatment rarely have been studied systematically in the population presenting to the emergency department. We conducted a study in patients presenting to the emergency department of the University of Bern.

METHODS

In this retrospective case series at a university hospital in Switzerland, 77,847 patients admitted to the emergency department between April 1, 2008, and March 31, 2011, were included. Serum sodium was measured in 43,911 of these patients. Severe hyponatremia was defined as less than 121 mmol/L, and severe hypernatremia was defined as less than 149 mmol/L.

RESULTS

Hypernatremia (sodium>145 mmol/L) was present in 2% of patients, and hyponatremia (sodium<135 mmol/L) was present in 10% of patients. A total of 74 patients had severe hypernatremia, and 168 patients had severe hyponatremia. Some 38% of patients with severe hypernatremia and 64% of patients with hyponatremia had neurologic symptoms. The occurrence of symptoms was related to the absolute elevation of serum sodium. Somnolence and disorientation were the leading symptoms in hypernatremic patients, and nausea, falls, and weakness were the leading symptoms in hyponatremic patients. The rate of correction did not differ between symptomatic and asymptomatic patients. Patients with symptomatic hypernatremia showed a further increase in serum sodium concentration during the first 24 hours after admission. Corrective measures were not taken in 18% of hypernatremic patients and 4% of hyponatremic patients.

CONCLUSIONS

Dysnatremias are common in the emergency department. Hyponatremia and hypernatremia have different symptoms. Contrary to recommendations, serum sodium is not corrected more rapidly in symptomatic patients.

Dysnatraemias in the emergency room: Undetected, untreated, unknown?

BACKGROUND

Hypo- and hypernatraemia are the most common electrolyte disorders in hospitalized patients and have been associated with increased mortality. However, data on the prevalence of dysnatraemias in the emergency room and the characteristics of patients presenting with them are rare.

METHODS

In this retrospective study, we analyzed data from patients who presented to the emergency department of a large tertiary university hospital between September 1st 2010 and November 30th 2010 and who received measurement of serum sodium.

RESULTS

3,182 patients received measurement of serum sodium during the three-month study period. 124 patients (4%) presented with hyponatraemia on admission to the emergency department while 400 patients (13%) presented with hypernatraemia. While there was no difference in age between patients with hypernatraemia and those who were normonatraemic, patients with hyponatraemia were significantly older.

CONCLUSION

Dysnatraemias are present in almost 1 in 5 patients who presented to the emergency department. Contrarily to patients who are already hospitalized, hypernatraemia was by far more common than hyponatraemia in patients at the emergency department. Surprisingly, patients with hyponatraemia were significantly older than normonatraemic patients while there was no age difference in hypernatraemic patients. Dysnatraemias are common in the emergency room and further studies are indicated to evaluate the causes and the impact on outcome of patients.

[Risk factors contributing to insufficient water intake in elderly living in nursing homes and long-term care units: a review of the literature]

Elderly living in nursing homes and long-term care units are well-known to be vulnerable to dehydration. Insufficient water intake contributes to suboptimal hydration status and leads to decreased quality of life and global health status. Based on published studies, 32 to 96% of nursing home residents had insufficient water intake and more than 50% drank less than 1.5L per day. Risk factors contributing to decreased water intake in nursing home residents can be divided into two categories, depending whether they apply to the individuals per se (individual factors) or their social and institutional environment (environmental factors). Water intake is associated with meals and medication administration frequency. Diminished thirst sensation, intentional fluid restriction, dysphagia and functional dependency are individual factors recognized as most contributing to decreased water intake. Lack of familial support and insufficient staff are also important since they can contribute to decreased patients' assistance. Dietitians can play a fundamental role in preventing suboptimal hydration status by identifying risk factors that are known to compromise individual's water intake and by implementing corrective measures.

A review of drug-induced hypernatraemia

Drug-induced electrolyte abnormalities have been increasingly reported and may be associated with considerable morbidity and/or mortality. In clinical practice, hypernatraemia (serum sodium higher than 145 mmol/L) is usually of multifactorial aetiology and drug therapy not infrequently is disregarded as a contributing factor for increased serum sodium concentration. Strategies to prevent this adverse drug effect involve careful consideration of risk factors and clinical and laboratory evaluation in the course of treatment. Herein, we review evidence-based information via PubMed and EMBASE and the relevant literature implicating pharmacologic treatment as an established cause of hypernatraemia and discuss its incidence and the underlying pathophysiologic mechanisms.

Developing a quick and practical screen to improve the identification of poor hydration in geriatric and rehabilitative care

Dehydration has been associated with increased morbidity and mortality. Dehydration risk increases with advancing age, and will progressively become an issue as the aging population increases. Worldwide, those aged 60 years and over are the fastest growing segment of the population. The study aimed to develop a clinically practical means to identify dehydration amongst older people in the clinical care setting. Older people aged 60 years or over admitted to the Geriatric and Rehabilitation Unit (GARU) of two tertiary teaching hospitals were eligible for participation in the study. Ninety potential screening questions and 38 clinical parameters were initially tested on a single sample (n = 33) with the most promising 11 parameters selected to undergo further testing in an independent group (n = 86). Of the almost 130 variables explored, tongue dryness was most strongly associated with poor hydration status, demonstrating 64% sensitivity and 62% specificity within the study participants. The result was not confounded by age, gender or body mass index. With minimal training, inter-rater repeatability was over 90%. This study identified tongue dryness as a potentially practical tool to identify dehydration risk amongst older people in the clinical care setting. Further studies to validate the potential screen in larger and varied populations of older people are required.

The epidemiology of intensive care unit-acquired hyponatraemia and hypernatraemia in medical-surgical intensive care units

INTRODUCTION

Although sodium disturbances are common in hospitalised patients, few studies have specifically investigated the epidemiology of sodium disturbances in the intensive care unit (ICU). The objectives of this study were to describe the incidence of ICU-acquired hyponatraemia and hypernatraemia and assess their effects on outcome in the ICU.

METHODS

We identified 8142 consecutive adults (18 years of age or older) admitted to three medical-surgical ICUs between 1 January 2000 and 31 December 2006 who were documented to have normal serum sodium levels (133 to 145 mmol/L) during the first day of ICU admission. ICU acquired hyponatraemia and hypernatraemia were respectively defined as a change in serum sodium concentration to below 133 mmol/L or above 145 mmol/L following day one in the ICU.

RESULTS

A first episode of ICU-acquired hyponatraemia developed in 917 (11%) patients and hypernatraemia in 2157 (26%) patients with an incidence density of 3.1 and 7.4 per 100 days of ICU admission, respectively, during 29,142 ICU admission days. The incidence of both ICU-acquired hyponatraemia (age, admission diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE) II score, length of ICU stay, level of consciousness, serum glucose level, body temperature, serum potassium level) and ICU-acquired hypernatraemia (baseline creatinine, APACHE II score, mechanical ventilation, length of ICU stay, body temperature, serum potassium level, level of care) varied according to patients' characteristics. Compared with patients with normal serum sodium levels, hospital mortality was increased in patients with ICU-acquired hyponatraemia (16% versus 28%, p < 0.001) and ICU-acquired hypernatraemia (16% versus 34%, p < 0.001).

CONCLUSIONS

ICU-acquired hyponatraemia and hypernatraemia are common in critically ill patients and are associated with increased risk of hospital mortality.

Elder mistreatment in the nursing home: a systematic review

Because of their significant dependence on others for their care, nursing home residents are potentially vulnerable to abuse and/or neglect. The topic of elder mistreatment, whether in the nursing home or other living environments, received little attention from clinicians and researchers until the past 2 decades. Original research is now emerging that sheds light on the scope of the problem and the challenges to timely prevention, identification, and management. Practitioners may use this information to recognize and change factors associated with a higher likelihood of nursing home mistreatment.

Clinical assessment of dehydration in older people admitted to hospital: what are the strongest indicators?

Due to an absence of published primary data, this study explores dehydration prevalence and the change in physiological parameters frequently used to assess dehydration (fluid deficit) in older hospitalized people, as no standard measurement method exists. This observational longitudinal cohort study recruited 43 people aged 60 years or over, voluntarily admitted to a tertiary teaching hospital's Geriatric and Rehabilitation Unit (GARU). Over 40 clinical, hematological and urinary biochemical parameters employed by medical officers during dehydration assessment, identified through literature, interviews and focus group were investigated. Short-term weight changes, intra- and inter-rater repeatability of dehydration assessments were completed to assess validation and precision of the clinician's clinical dehydration assessment. Systolic blood pressure drop on standing, sternal skin turgor, tongue dryness and body mass index (BMI) were associated with hydration status; demonstrated clinically meaningful differences between groups. BMI negatively confounded the association between dehydration and systolic blood pressure drop on standing. Physical, rather than biochemical, parameters more often identified mild dehydration. The findings challenge common expectations of hematological and physiological measurement changes occurring in older people clinically assessed as dehydrated and emphasize the need to adjust for potential confounders during exploration of the associations of clinical parameters with dehydration status.

Bouncing back: patterns and predictors of complicated transitions 30 days after hospitalization for acute ischemic stroke

OBJECTIVES

To identify predictors of complicated transitions within 30 days after discharge from hospitalization for acute stroke.

DESIGN

Retrospective analysis of administrative data.

SETTING

Four hundred twenty-two hospitals in the southern and eastern United States.

PARTICIPANTS

Thirty-nine thousand three hundred eighty-four Medicare beneficiaries aged 65 and older discharged after acute ischemic stroke from 1998 to 2000.

MEASUREMENTS

Complicated transition, defined as movement from less- to more-intensive care setting after hospital discharge, with hospital being most intensive and home without home health care being least intensive.

RESULTS

Twenty percent of patients experienced at least one complicated transition; 16% of those experienced more than one complicated transition. After adjustment using logistic regression, factors predicting any complicated transition included older age, African-American race, Medicaid enrollment, prior hospitalization, gastrostomy tube, chronic disease, length of stay, and discharge site. Patients with multiple complicated transitions were more likely to be African American (odds ratio (OR)=1.38, 95% confidence interval (CI)=1.13-1.68), be male (OR=1.21, 95% CI=1.04-1.40), have a prior diagnosis of fluid and electrolyte disorder (e.g., dehydration) (OR=1.23, 95% CI=1.07-1.43), have a prior hospitalization (OR=1.18, 95% CI=1.01-1.36), and be initially discharged to a skilled-nursing facility or long-term care (OR=1.22, 95% CI=1.04-1.44) than patients with only one complicated transition. They were less likely to be initially discharged to a rehabilitation center (OR=0.71, 95% CI=0.57-0.89).

CONCLUSION

Significant numbers of stroke patients experience complicated transitions soon after hospital discharge. Sociodemographic factors and initial discharge site distinguish patients with multiple complicated transitions. These factors may enable prospective identification and targeting of stroke patients at risk for "bouncing back."

Clinical Presentation of Hypernatremia in Elderly Patients: A Case Control Study

OBJECTIVES

To assess early clinical signs and their prognostic value in elderly patients with hypernatremia.

DESIGN

Prospective, case control study of 150 patients with hypernatremia matched to 300 controls.

SETTING

Multicenter study including seven short- and long-term geriatric care facilities.

MEASUREMENTS

Clinical assessment of hydration status at bedside, such as abnormal skin turgor or dry oral mucosa.

SECONDARY OUTCOME MEASURES

30-day mortality rate and clinical indicators (assessed at the peak of natremia) associated with mortality.

RESULTS

Patients and controls were comparable in terms of drugs and underlying diseases, except for history of dementia, which was more frequent in patients than in controls. Patients were significantly more likely than controls to have low blood pressure, tachycardia, dry oral mucosa, abnormal skin turgor, and recent change of consciousness. Only three clinical findings were found in at least 60% of patients with hypernatremia: orthostatic blood pressure and abnormal subclavicular and forearm skin turgor. The latter two signs were significantly more frequent in patients with hypernatremia. Four other signs (tachycardia, abnormal subclavicular skin turgor, dry oral mucosa, and recent change of consciousness) had a specificity of greater than 79%. Using logistic regression, four signs were significantly and independently associated with hypernatremia: abnormal subclavicular and thigh skin turgor, dry oral mucosa, and recent change of consciousness. The mortality rate was 41.5% and was significantly higher in patients with hypernatremia. The status of consciousness when hypernatremia was diagnosed was the single prognostic indicator associated with mortality (odds ratio=2.3, 95% confidence interval=1.01-5.2).

CONCLUSION

Most of the classical signs of dehydration are irregularly present in patients with hypernatremia. Caregivers should carefully screen any variations in consciousness, because they may reveal severe hypernatremia.

Hypernatremia in the neurologic intensive care unit: how high is too high?

Hypernatremia is associated with increased mortality in hospitalized patients and in medical/surgical intensive care units. This relationship has not been studied in neurologic/neurosurgical intensive care units (NNICUs), where hypernatremia is often a component of treatment of cerebral edema. We performed a retrospective analysis of prospectively collected data in patients admitted to the NNICU over a 6.5-year period. Hypernatremia (serum sodium >150 mEq/L) was seen in 339 patients (7.9%) and was more common (24.3%) in patients who were treated with mannitol. Hypernatremic patients had a lower median admission Glasgow Coma Scale score (8 vs 14, P < .001), higher initial Acute Physiology and Chronic Health Evaluation II probability of death (34.9% vs 19.1%, P < .001), higher incidence of mechanical ventilation (80.5% vs 41.1.5%, P < .001), higher mortality (30.1% vs 10.2%, P < .001), and higher incidence of renal failure (10.3% vs 0.9%, P < .001). Mortality increased with increasing hypernatremia; however, only severe hypernatremia (serum sodium >160 mEq/L) was independently associated with increased mortality. Other factors independently associated with mortality were age, mechanical ventilation, initial Acute Physiology and Chronic Health Evaluation II probability of death or low admission Glasgow Coma Scale score, and a diagnosis of cerebrovascular disease. In conclusion, hypernatremia is common in the NNICU, more so in patients treated with mannitol. In this population, severe (but not mild or moderate) hypernatremia is independently associated with increased mortality.

Water and sodium disturbances predict prognosis of acute disease in long term cared frail elderly

Elderly patients are at increased risk for developing infections and fever. We aimed to investigate the incidence, causes and outcome of hypernatemia and hyponatremia among elderly long-term care patients with febrile illness. This is a prospective study conducted in a 110 beds, nursing department for dependent elderly in geriatric long-term care facility during 20 months period. Changes in plasma sodium concentrations were found in 48% (132/270) of the febrile illness: during the acute illness in 38% (102/270) of the events and during the follow-up period after acute febrile event, in 30% (59/198) of the events. Upper respiratory tract, bronchial, lung, and urinary tract infections were the most common causes for the fever. Hypernatremia was more prevalent on acute febrile illness (63%). Hyponatremia was more common before the febrile illness (10%) and during the follow-up period (69%). The most common causes of hypernatremia were inadequate hydration or correction (57%) and continuous diuretic treatment (38%). The most common causes of hyponatremia were: Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) (38%), incorrect hydration (19%), and continuous diuretic treatment (30%). During the study, 60% (28/47) of the patients died, and hypernatremia was detected in 82% (20/28). Disturbances in sodium concentrations were predictors of bad outcomes, related to the underlying diseases burden, and were not related to the magnitude of the changes in plasma sodium, time of its development, advanced age, gender and coexisting changes in plasma potassium level.

UNRECOGNIZED Chronic Dehydration in Older Adults: Examining Prevalence Rate and Risk Factors

Dehydration has serious consequences for older adults, including increased risk of illness or death. This retrospective review of medical records describes the prevalence, assessment, and risk factors for chronic dehydration in 185 older adults who visited an emergency department in June 2000. Results showed chronic dehydration was present in 89 (48%) patients. Physicians documented assessment for signs of dehydration in 23 (26%) of the dehydrated older adults, but no independent assessments for dehydration were recorded by nurses. These findings indicate many older adults may suffer from unrecognized dehydration, and nurses should be alert to the possibility that dehydration may be present in community-dwelling older adults as well as those who live in residential facilities.

Maintaining oral hydration in older adults: a systematic review

Dehydration is the most common fluid and electrolyte imbalance in older adults. The objectives were to identify the factors that increase the risk of dehydration in older adults, how best to assess the risk and manage oral fluid intake. Data sources included Medline, CINAHL, Cochrane Library, Embase and Current Contents, which were searched until February 2002. Randomized controlled trials for management of adequate fluid intake were undertaken. Cohort and case control studies were used for the identification of risk factors for dehydration. Studies of assessment tools for the identification of dehydration were also considered. Results show that there is no clear determination of the risk factors for dehydration and decreased fluid intake. The recommended daily intake of fluids should be not less than 1600 mL/24 h in order to ensure adequate hydration. A fluid intake sheet and urine specific gravity might be the best methods of monitoring daily fluid intake. Regular presentation of fluids to bedridden older adults can maintain adequate hydration status. In conclusion, more research is required to determine the optimum method of maintaining adequate oral hydration in older adults.

Survival with serum sodium level of 180 mEq/L: permanent disorientation to place and time

A 41-year-old woman who had undergone transfrontal craniotomy for a pituitary tumor 4 months before presentation was admitted with confusion and orientation only to self. She had a fever of 40 degrees C. Serum sodium and chloride levels on admission were 180 and 139 mEq/L, respectively. Measured serum osmolality was 380 mOsmol/L with a urine osmolality of 360 mOsmol/L. Magnetic resonance imaging revealed a 1.5-cm mass in the sella turcica, which was nonfunctioning on endocrine evaluation. The "bright spot" of a normal posterior pituitary was absent. Central diabetes insipidus was confirmed by a 300% increase in urine osmolality with desmopressin. The patient survived her severe hypernatremia, which has 70% mortality with a serum sodium level of 160 mEq/L or above. However, she developed permanent (6 months) disorientation to time and place even when hypernatremia was corrected, which has not been described previously.

Monitoring hydration status in elderly veterans

Dehydration is a common water and electrolyte disorder in long-term care residents. Practical methods to detect and monitor dehydration are needed. This study determined whether urine color measured by a urine color chart reflects hydration status. The study employed a repeated measures design with two observations during a 10-hour period. Urine color was compared to the criterion standard of urine specific gravity and osmolality. The sample included 89 participants from two Veterans' Affairs facilities. Urine color was graded on an eight-level color chart. Urine specific gravity and osmolality, serum sodium and osmolality, hematocrit, blood urea nitrogen (BUN), and creatinine were measured using standard laboratory procedures. Significant positive associations existed between urine color and both urine specific gravity and urine osmolality and between urine osmolality and serum sodium and the blood urea nitrogen to creatinine ratio. Although further testing is needed, the color chart has potential as a low-cost technology to monitor dehydration.

Severe dementia and adverse outcomes of nursing home-acquired pneumonia: evidence for mediation by functional and pathophysiological decline

OBJECTIVES

To assess whether the severity of dementia is related to unfavorable outcomes of nursing home-acquired pneumonia and how this relationship is mediated.

DESIGN

Prospective cohort study.

SETTING

Psychogeriatric wards of 61 nursing homes in the Netherlands.

MEASUREMENTS

Dementia severity and the possible mediators swallowing disturbance, aspiration, insufficient food intake, weight loss, and dehydration were measured and related to the following outcomes: death (rate), cure rate, and increase in discomfort at the onset of pneumonia.

PARTICIPANTS

Demented patients (n = 374) treated with antibiotics for pneumonia.

RESULTS

Dementia severity was independently related to death rate within the first week after pneumonia (hazard rate ratio = 3.0 for the most severely demented quartile versus the least demented quartile, 95% confidence interval (CI) = 1.1-8.3) and to 3-month mortality (odds ratio (OR) 2.5, 95% CI = 1.1-5.4). The latter relation was in part mediated by aspiration and weight loss (OR dementia severity adjusted for these mediators declined from 2.5 to 1.9, 95% Cl = 0.8-4.3). Dementia severity was not related to cure rate within 2 weeks nor to an in-crease in discomfort after 3 days compared with before the pneumonia.

CONCLUSION

The functional and pathophysiological consequences of progressive dementia account in part for increased 3-month mortality after pneumonia. Mid-term mortality is expected to be high only in the most severely demented patients and in less severely demented patients who aspirated or who lost weight. Implications for end-of-life decision-making and effectiveness of preventive and curative interventions are discussed.

The reproducibility of a new dietary record routine in geriatric patients

BACKGROUND AND AIM

Malnutrition in nursing home residents is an important clinical and public health problem. Knowledge is lacking about the reproducibility of dietary recording in geriatric patients. Few studies have described water intake in this age group. The aim of this study was to test the reproducibility of a 7-day dietary record routine in a clinical setting.

METHODS

The dietary intake of 81 geriatric patients was recorded for two discrete periods of 7 consecutive days by the ward staff. The dietary record routine, which assessed both food and fluid intake, was based on standardized portion sizes and household measurements.

RESULTS

The mean daily energy intake during the first period was 7.07 MJ and 6.84 MJ during the second period, with a mean difference of 4%. Corresponding values and the mean difference for water intake from food and beverages were 1781 g, 1702 g and 4% respectively. Age, gender, diagnosis, length of stay, diets or ADL function did not influence the results. The correlation coefficient for fluid intake between the periods was 0.84 for women and 0.72 for men.

CONCLUSION

The 7-day dietary record routine seems to have a good reproducibility in assessing the intake of energy and fluids in geriatric patients.

Dehydration: hazards and benefits

Dehydration is a serious risk for elders because total body water decreases with age, aging kidneys are less able to concentrate urine, and the sensation of thirst decreases. Geriatric nurses traditionally have assessed for dehydration, but its signs are difficult to detect in many patients. Instead, nurses, assistive personnel, and family members must work to prevent dehydration in elders. In contrast, dehydration may be beneficial to patients during the final stage of a terminal illness, although the decision to withhold or withdraw medical hydration may present a legal and ethical dilemma for nurses.