This website uses cookies. By continuing to use this website you are giving consent to cookies being used. For information on cookies and how you can disable them visit our Privacy and Policy.
1Northumbria Healthcare NHS Foundation Trust, Stroke Research, Wansbeck General Hospital, Woodhorn Lane, Ashington, Northumberland NE63 9JJ UK
Find articles by Lloyd L. Oates
Christopher I. Price
1Northumbria Healthcare NHS Foundation Trust, Stroke Research, Wansbeck General Hospital, Woodhorn Lane, Ashington, Northumberland NE63 9JJ UK
2Newcastle University Institute for Ageing, Newcastle University Stroke Research Group, 3-4 Claremont Terrace, Newcastle upon Tyne, NE1 7RU UK
Find articles by Christopher I. Price
Disclaimer
1Northumbria Healthcare NHS Foundation Trust, Stroke Research, Wansbeck General Hospital, Woodhorn Lane, Ashington, Northumberland NE63 9JJ UK
2Newcastle University Institute for Ageing, Newcastle University Stroke Research Group, 3-4 Claremont Terrace, Newcastle upon Tyne, NE1 7RU UK
Lloyd L. Oates, Email: ku.shn.tchn@setaO.dyolL.
.
Received 2016 Jul 15; Accepted 2016 Dec 1.
Copyright © The Author[s]. 2016
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License [//creativecommons.org/licenses/by/4.0/], which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author[s] and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver [//creativecommons.org/publicdomain/zero/1.0/] applies to the data made available in this article, unless otherwise stated.
Associated Data
All relevant data can be found within the manuscript. For a more detailed description of the search strategy please see Additional file . Any further information can be found by application to the corresponding author.
Abstract
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.
Electronic supplementary material
The online version of this article [doi:10.1186/s12912-016-0195-x] contains supplementary material, which is available to authorized users.
Keywords: Dehydration, Drinking, Fluid therapy, Nursing care, Risk assessment
Background
Older adults are susceptible to dehydration due to acute and chronic health problems, which impair thirst, reduce the ability to drink sufficiently and/or increase urinary, skin and respiratory fluid loss []. During hospitalisation negative fluid balance often accompanies infection and is independently associated with poorer outcomes [–], longer length of stay and greater costs [–]. In England the National Institute for Healthcare and Care Excellence has estimated that the annual impact from acute kidney injury is up to £620 million [] and that 12,000 cases could be avoided by more pro-active fluid management amongst vulnerable groups such as older adults. Specific associations with dehydration have already been described with acute stroke [], and admission from a long term care setting []. Although it is a clinical priority to recognise and address risks of insufficient oral fluid intake, there is no standardised nurse-led assessment or formal bedside response protocol commonly applied. A recent Cochrane review [], of studies to identify impending and current water loss in an older people recommended that for clinical practice “there is no clear evidence for the use of any single clinical symptom, sign or test of water-loss dehydration in older people. Where healthcare professionals currently rely on single tests in their assessment of dehydration in this population this practice should cease because it is likely to miss cases of dehydration [as well as misclassify those without water-loss dehydration].” Previous studies have recommended combining various data items to identify individuals, who may need fluid support interventions. Some studies have often confused a risk of inadequate fluid intake with characteristics already indicating a dehydrated state or relied upon serial laboratory measures of renal function and osmolality [, ]. In the absence of a single test/symptom based upon an objective reference standard of hydration status, our aim was to look qualitatively at the evidence for any assessment [including multiple combinations of factors] and matching intervention which could be easily used at the bedside specifically to reduce the risk of dehydration [not to identify an already dehydrated state]. This would not be restricted to studies attempting to validate against laboratory measures of fluid status. In order to make recommendations regarding care processes during hospitalisation, studies would be selected from institutional settings, including care homes.
Methods
Using PRISMA guidelines [] articles published in English were sought where the main focus was use of a hydration/dehydration assessment in an adult population with/without a care intervention to promote oral hydration. Review articles were included where a new assessment tool was developed as a result of findings. Articles were excluded which described single case reports, laboratory results only, technology which was not integrated into a clinical score e.g. bioelectrical impedance analysis [BIA] or non-oral fluid replacement in patients who were already dehydrated. Interventional studies were included if the intention was specifically to promote oral hydration rather than nutritional intake in general.
A search of electronic databases [MEDLINE, EMBASE and CINAHL] was conducted using keywords: dehydration, prevention, assessment, screening, hospitals and care homes. The reference lists of identified papers were cross-referenced for new articles. Grey literature [non published academic work, hospital protocols and existing dehydration assessment tools] was sought through Google and Google Scholar. Interventional studies were included if the intention was specifically to promote oral hydration rather than nutritional intake in general. A structured data extraction and quality appraisal form was used for information extraction including: design, population and identification, method of data collection, results, ethical considerations, key ideas and author’s conclusions [–]. The first author [LO] screened initial titles and abstracts. Two authors [LO,CP] independently reviewed full text articles. Differences were resolved in scheduled meetings. Due to the mixed nature of the studies and uncertainties about the generalizability of different settings, results are presented as a narrative synthesis and no additional analysis was performed. The protocol was registered with the PROSPERO International prospective register of systematic reviews [PROSPERO 2014:CRD42014015178]. Fuller details of the search methods are available from the corresponding author.
Results
Search results
Figure 1 describes the study selection process. A total of 3973 articles were identified, after removing duplicates 3893 remained. Out of 3893 retrieved articles, 3805 were excluded by title and/or abstract, 69/88 full text articles were excluded because they were duplicate or single case reports, did not focus on dehydration prevention or oral fluid risk management and/or only considered additional non-oral fluid replacement strategies for patients who were already known to be dehydrated. Within the reference lists of the remaining articles a further four relevant papers were identified.
Open in a separate window
Fig. 1
Search results flow diagram. The figure shows the flow diagram of the search results under PRISMA headings of identification, screening, eligibility and included
Table 1 describes a summary of the extracted data. Of the 23 articles there were eight intervention studies, six non-systematic literature reviews, two guidelines, one assessment proposal, two audits, one multi-phase project summary and three surveys. Publication dates ranged from 1984 to 2016. Countries of origin were USA [nine], UK [eight], Australia [five] and Italy [one]. Comparison of quality was challenging due to the variable nature of the articles; however most had a clear stated aim and identified their target setting. The search did not identify adequately powered randomised controlled trials and large prospective observational studies. The individual risk factors for poor hydration reported across the 23 included articles are summarised below. To describe the clinical context of each assessment or intervention, each article has then been placed into one of five groups: identification checklist/chart [five], identification checklist/chart with care intervention [five], identification by urinary inspection [two], promotion of oral intake [four], professional knowledge/awareness improvement [seven], as seen in Table 1.
Table 1
Summary of extracted data
GroupFirst author, Year, CountryClear statement of aimsArticle TypeSettingPurposeParticipantsMean AgeFemale [%]Results/RecommendationsIdentification checklist/chartVivanti [2010] Australia []YObservational prospective analysisHospitalScreening questions and clinical parameters in hydrated and dehydrated patients.86 [36 dehydrated]78.654.7Inter rater repeatability 70–95% agreement.SensitivitySpecificityTongue dryness64%,[95% CI 54–74%]62%, [95% CI 52–72%]Pain interference83%, [95% CI 76–90%]32%, [95% CI 23–43%]Drop in systolic BP69%, [95% CI 59–79%]56%, [95% CI 46–66%]Skin turgor44% [95% CI 34–54%]65% [95% CI 55–75%]The authors identified tongue dryness as a clinical feature to identify dehydration amongst older people. Further studies were recommended.Identification checklist/chartVivanti [2008] Australia []YObservational prospective analysisHospitalOver 40 clinical parameters were explored in hydrated and dehydrated patients.43 patients
8 Focus Group
9 Interviews78.365Presence of mild dehydration:Tongue dryness71.4%,[OR 4.4 [95% CI 0.8–26.1]]Tongue furrow57.1%, [OR 3.0 [95% CI 0.5–15.8]]Dry oral mucous membrane57.1%, [OR 2.3 [95% CI 0.4–12.0]]Tissue turgor hand88.7%, [OR 2.6 [95% CI 0.2–24.6]]Tissue turgor sternum14.3%, [OR 5.8 [95% CI 0.3–106.4]]DehydratedHydratedp valueSystolic BP standing drop20.1 ± 20.8 mmHg2.1 ± 19.0 mmHg0.03BMI20.0 ± 3.027.5 ± 6.20.03Weight46.7 kg71.5 kg0.04The authors reported that physical, rather than biochemical, parameters more often identified mild dehydration.Identification checklist/chartBulgarelli [2015] Italy []YObservational prospective analysisHospitalEvaluation of the DRAC21 [received checklist]8054.7Patient’s scores evaluated within 3 days of admission and at discharge. Scores on the DRAC did not significantly change between admission and discharge and were not correlated with laboratory measures of dehydration.Identification checklist/chartMentes [2011] USA []YObservational retrospective analysisNursing HomeEvaluated the DRAC using a factor analysis, and multiple logistic regression.133 [9 Nursing Homes]83.156.440 items were reduced to 17 based on frequency distribution. The remaining factors were examined for their association with dehydration, which varied from −0.012 [female gender] to 0.567 [urinary incontinence]. See Table 3 for the factors included. Overall there was low to moderate association with dehydration. An increased number of risk items indicate a greater overall risk.Identification checklist/chartWotton [2008] Australia []YReviewN/AReviewed risk factors and explored the reliability of clinical signs.N/AN/AN/AThe authors concluded that the management of fluid and electrolyte balance requires a complex mixture of skills including knowledge, expertise and an understanding of the underlying physiological principles of fluid balance in the body. The use of multiple patient assessment cues should be used by nurses to differentiate between and respond to the various causes of dehydration. Actions include education for older adults on adequate fluid intake, visual reminders to drink, increased offering of fluids between meals and special drinking apparatus or swallowing exercise.Identification checklist/chart with care interventionFood First team [2012] United Kingdom [England] []NClinical guidelineHospitalReporting of a checklist with an accompanying response protocol.N/AN/AN/ARecommendations were to assess 24 h fluid intake, urine colour, and symptoms associated with dehydration risk before formalising an individual hydration plan.Identification checklist/chart with care interventionKeller [2006] Australia []YAuditNursing HomeUse of an audit tool to measure current practice against best practice.Pre-audit 96
Post-audit 1565