115Among the older adult population, a significant risk is that of dehydration affecting 20% to 30% of older adults (Miller, 2015). The consequences and complications of dehydration are prevented when early signs are identified and promptly treated. Untreated dehydration will progress to inability to control temperature, inability to sweat, development of fever, and diminished cardiac output (Miller, 2015). Although most patients with early signs of dehydration can be managed with increasing oral intake, those with moderate dehydration may benefit from infusion therapy. Besides the older and chronically ill population, other patient populations that may require infusion fluid replacement to prevent dehydration include pregnant women with hyperemesis gravidarum and patients who are undergoing chemotherapy. Home treatment has been found successful in reducing the risk for rehospitalization and emergency room visits (Konrad et al., 2016).

After reading this chapter, the reader will be able to:

116DEHYDRATION: AN OVERVIEW

Dehydration is defined by a decline in total body water. The most common type of dehydration is isotonic dehydration resulting from an equal loss of water and electrolytes (Miller, 2015). Causes include diarrhea, vomiting, or inadequate fluid intake. Hypertonic dehydration is a result of excessive sodium in the extracellular fluid, a result of diuretics or inadequate fluid intake. Older adults are at higher risk for dehydration due to a number of factors that include natural changes associated with aging. These include a decreased percentage of total body water (60% in younger adults to 40% in older adults), decreased muscle mass (muscles store a large amount of water), decreased capacity to concentrate urine, and a decrease in the sensation of thirst. Other risk factors include age greater than 85 years, dependence on others for feeding and eating, dementia, presence of an infection, four or more chronic conditions, four or more medications, taking diuretics, vomiting/diarrhea, and prior episodes of dehydration (Mentes, 2012). A medication review is very important as polypharmacy is often a significant contributing factor to dehydration (Miller, 2015).

Signs and symptoms of dehydration are often unreliable in older adults. A rapid weight loss over 1 to 2 weeks should signal the possibility of dehydration (Morley, 2015). Mild dehydration is categorized by a water loss equivalent to 1% of body weight and by symptoms that include headache, fatigue, weakness, dizziness, and lethargy. Moderate dehydration may include additional symptoms of dry mouth, decreased urine output, and decreased skin elasticity. Skin turgor in older adults is usually not reliable, but if done should be checked on the forehead.

In terms of laboratory studies, they are not always reliable indicators in older adults. For example, the blood urea nitrogen (BUN) to serum creatinine level (>20) is a common measure of dehydration but is not reliable in older adults because a multitude of other factors may cause an elevation such as aging muscle loss, presence of renal/heart failure, glucocorticoids, and increased protein intake (Morley, 2015). While the serum osmolality has been reported as the gold standard to diagnose dehydration (Miller, 2015), making the diagnosis of dehydration is actually quite challenging. A level of more than 295 mOsm/kg may indicate a hyperosmolar state and dehydration. Urinalysis may also be helpful providing information about specific gravity (high), color, and presence of leukocytes, nitrites, and blood, which may indicate a urinary tract infection that could be a cause of decreased fluid intake. In a Cochrane review, no tests were found to be consistently useful in 117diagnosing water-loss dehydration in older adults; the researchers assert that the following tests should not be used to diagnose dehydration: dry mouth, feeling thirsty, heart rate, and urine color and volume (Hooper et al., 2015). In a clinical article, the authors suggest clinical observations should be based on the patient history, physical assessment, laboratory values, and clinician experience (Armstrong, Kavouras, Walsh, & Roberts, 2016). Clearly, comprehensive assessment by the home care nurse in interprofessional collaboration with the physician and the pharmacist is essential in making the best decision in identification of and treatment of dehydration.

For patients with evidence suggesting severe dehydration such as fever, confusion, and little to no urination, hospitalization is recommended as it is considered a medical emergency (Miller, 2015). For patients with moderate dehydration, infusion fluid administration may be appropriate and hypodermoclysis is suggested.

Infusion Fluid Replacement: IV versus SC Administration

For younger adults with good vascular access or the presence of an existing vascular access device (VAD), the IV route is a more common infusion route. Patients with cancer who are experiencing side effects impacting fluid intake may have an implanted port or other central VAD (CVAD) that may be used for fluid replacement. Patients with conditions such as hyperemesis gravidarum may require longer courses of fluid replacement until symptoms recede and a peripheral or midline catheter (shorter term needs) or CVAD such as a peripherally inserted central catheter (PICC) is often placed for fluid needs.

Primarily used in the older adult with dehydration, SC infusion is an alternative to IV administration of isotonic fluids as presented in Chapter 6. SC infusion of hydration fluids is called “hypodermoclysis.” Hypodermoclysis is generally indicated as a short-term infusion therapy, generally for 2 to 3 days or less. Hypodermoclysis is underutilized in the home care setting due to lack of understanding of the route and concerns about how patients would tolerate or experience this route. Advantages to hypodermoclysis include ease of initiation, minimal adverse reactions, and ability to administer a reasonable volume. Note that hypodermoclysis is a route that has been used since the 1950s and is today seeing a resurgence as it is recognized as a relatively easy, low-risk, and cost-effective method for delivery of hydration fluids in patients with mild to moderate dehydration (Caccialanza et al., 2016; Humphrey, 2011; Scales, 2011). The most commonly administered 118isotonic fluids include 0.9% sodium chloride and 5% dextrose in water. In an older study that included 30 long-term care residents from 24 to 90 years of age, who received SC infusions from 1 to 2 days for dehydration, all infusions were completed without adverse effects except for one incidence of local edema at the site (Walsh, 2005).

PATIENT SELECTION CONSIDERATIONS

■  The patient and family are motivated and willing and capable of participating in infusion management.

■  The patient is clinically stable.

       The patient is exhibiting signs of mild to moderate dehydration; treatment of severe dehydration would not be appropriate in the home.

       The patient is at known risk for dehydration (e.g., expected side effects with chemotherapy, and hyperemesis gravidarum).

■  An appropriate infusion route is selected.

       Short peripheral IV catheters, midline peripheral catheters, or PICCs are common VADs that may be used for fluid replacement.

       SC route is appropriate for older adults or other adults with limited venous access and no existing VAD.

■  The home environment is safe, clean, with adequate refrigeration space, and the patient has ready access to a telephone.

■  Reimbursement is verified.

       Private third-party payers vary in coverage.

COMPREHENSIVE CARE, ASSESSMENT, AND MONITORING

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