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November 15, 1995, Vol 274, No. 19 >
Council Report | November 15, 1995

Dehydration: Title and subTitle BreakEvaluation and Management in Older Adults

Andrew D. Weinberg, MD; Kenneth L. Minaker, MD; Yank D. Coble, Jr, MD; Ronald M. Davis, MD; C. Alvin Head, MD; John P. Howe, III, MD; Mitchell S. Karlan, MD; William R. Kennedy, MD; Patricia Joy Numann, MD; Monique A. Spillman; W. Douglas Skelton, MD; Richard M. Steinhilber, MD; Jack P. Strong, MD; Henry N. Wagner, Jr, MD; James R. Allen, MD, MPH; Robert C. Rinaldi, PhD;
[+] Author Affiliations

The recommendations of Report 1 of the Council on Scientific Affairs were adopted at the 1994 House of Delegates Annual Meeting and the remainder of the report was filed.

This report is not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on the basis of all the facts and circumstances involved in an individual case and are subject to change as scientific knowledge and technology advance and patterns of practice evolve. This report reflects the scientific literature as of April 1995.

Reprint requests to Group on Science, Technology, and Public Health, Council on Scientific Affairs, American Medical Association, 515 N State St, Chicago, IL 60610 (James R. Allen, MD, MPH).


Jacksonville, Fla (Chair); Lansing, Mich; (Resident Representative), Boston, Mass; San Antonio, Tex; Beverly Hills, Calif; Minneapolis, Minn; Syracuse, NY; (Medical Student Representative), Dallas, Tex; Macon, Ga; Cleveland, Ohio; New Orleans, La; Baltimore, Md. Council on Scientific Affairs staff

From the Geriatrics and Extended Care Service, Brockton/West Roxbury Veterans Affairs Medical Center, Brockton, Mass (Drs Weinberg and Minaker); the Division on Aging, Harvard Medical School, Boston, Mass (Drs Weinberg and Minaker); and the Council on Scientific Affairs, American Medical Association, Chicago, Ill.


JAMA. 1995;274(19):1552-1556. doi:10.1001/jama.1995.03530190066035
Text Size: A A A
Published online
Article
References

Objective.  —To review published literature regarding dehydration in older individuals and formulate a consensus on the evaluation and treatment of this unrecognized cause of hospitalizations, morbidity, and mortality.

Data Sources and Study Selection.  —The literature concerning dehydration in the elderly population from MEDLINE was reviewed from 1976 through 1995. Search terms included dehydration, elderly, evaluation, hospitalization, and treatment. Particular emphasis was placed on articles describing original research leading to the development of new information on the evaluation and treatment of dehydration and review articles relating to the epidemiology, detection, treatment and health outcomes of this syndrome common in the geriatric population, including frail, institutionalized individuals.

Data Extraction.  —Data contributing to a broad scientific understanding of dehydration were initially grouped according to topic areas of the physiology of normal aging, illness-associated clinical reports of dehydration in the elderly population, and diagnostic and therapeutic interventions. The authors developed a consensus based on the weight of evidence presented and the authors' experience in the field.

Conclusions.  —Early diagnosis is sometimes difficult because the classical physical signs of dehydration may be absent or misleading in an older patient. Many different etiologies place the elderly at particular risk. In patients identified as being at risk for possible dehydration, an interdisciplinary care plan with regard to prevention of clinically significant dehydration is critical if maximum benefit is to result.(JAMA. 1995;274:1552-1556)

REFERENCES

1 +
Lavizzo-Mourey R, Johnson J, Stolley P.  Risk factors for dehydration among elderly nursing home residents. J Am Geriatr Soc . 1988;;36:213-218.
2 +
Daley J. Medicare Discharge Data, 1984-1987 . Brockton, Mass: Health Services Research and Development, Brockton/West Roxbury Veterans Affairs Medical Center; July 1993;.
3 +
Office of Research and Demonstration. Medicare and Medicaid Data Book, 1988 . Baltimore, Md: US Dept of Health and Human Services; 1988;: 37. Health Care Financing Adminstration publication 03270.
4 +
Vital and Health Statistics from the Centers for Disease Control and Prevention/National Center for Health Statistics. Detailed Diagnoses and Procedures, National Hospital Discharge Survey 1991 . Washington, DC: US Dept of Health and Human Services; February 1994;.
5 +
Health Care Financing Review. Medicare and Medicaid Statistical Supplement, 1992 Annual Supplement . Washington, DC: US Dept of Health and Human Services, Health Care Financing Administration, Office of Research and Demonstrations; October 1993;, vol 63. Health Care Financing Administration publication 0334.
6 +
Mahowald JM, Himmelstein DU.  Hypernatremia in the elderly: relation to infection and mortality. J Am Geriatr Soc . 1981;;29:177-180.
7 +
Long CA, Marin P, Bayer AJ, et al.  Hypernatremia in an adult in-patient population. Postgrad Med J . 1991;;67:643-645.
8 +
Himmelstein Du, Jones AA, Woolhandler S.  Hypernatremic dehydration in nursing home patients: an indicator of neglect. J Am Geriatr Soc . 1983;;31: 466-471.
9 +
6.2 CFR §483.25.
10 +
Adams F.  How much do elders drink? Geriatr Nurs . 1988;;9:218-221.
11 +
Gaspar PM.  What determines how much patients drink? Geriatr Nurs . 1988;;9:221-224.
12 +
Phillips PA, Roll BJ, Ledingham JG, et al.  Reduced thirst after water deprivation in healthy elderly men. N Engl J Med . 1984;;311:753-759.
13 +
Phillips PA, Bretherton M, Johnston CI, et al.  Reduced osmotic thirst in healthy elderly men. Am J Physiol . 1991;;261:R166-R171.
14 +
Silver AJ.  Aging and risks for dehydration. Cleve Clinic J Med . 1990;;57:341-344.
15 +
Crane MG, Harris JJ.  Effect of aging on renin activity and aldosterone excretion. J Lab Clin Med . 1976;;87:947-959.
16 +
Kirkland J, Lye M, Goddard F, et al.  Plasma arginine vasopressin in dehydrated elderly patients. Clin Endocrinol . 1984;;20:451-456.
17 +
Phillips PA, Johnston CI, Gray L.  Disturbed fluid and electrolyte homeostasis following dehydration in elderly people. Age Ageing . 1993;;22:S26-S33.
18 +
Rowe JW.  Renal system.  In: Rowe JW, Besdine RW, eds. Health and Disease in Old Age . Boston, Mass: Little Brown & Co; 1982;:165-183.
19 +
Silver AJ, Morley JE.  Role of the opioid system in the hypodipsia associated with aging. J Am Geriatr Soc . 1992;;40:556-560.
20 +
Wei JY, Gersh BJ.  Heart disease in the elderly. Curr Prob Cardiol . 1987;;12:1-65.
21 +
Luft FC, Weinberger MH, Grim CE, et al.  Sodium sensitivity in normotensive human subjects. Ann Intern Med . 1983;;98:758-762.
22 +
Rowe JW, Andres R, Tobin JD, et al.  The effect of age on creatinine clearance in men: a cross sectional and longitudinal study. J Gerontol . 1976;;31: 155-163.
23 +
Weinberg AD, Pals JK.  Assessment and treatment of dehydration in long-term care patients. Top Geriatr Med Nurs Home Care . 1993;;8:1-4.
24 +
Hoffman NB.  Dehydration in the elderly: insidious and manageable. Geriatrics . 1991;;46:35-38.
25 +
Pals JK, Weinberg AD, Beal LF, et al.  Clinical triggers for detection of fever and dehydration: implications for long-term care nursing. J Gerontol Nurs . 1995;;21:13-19.
26 +
Gross CR, Lindquist RD, Woolley AC, et al.  Clinical indicators of dehydration severity in elderly patients. J Emerg Med . 1992;;10:267-274.
27 +
Wandel JC.  The use of postural signs in the assessment of fluid volume status. J Prof Nurs . 1990;;6:46-54.
28 +
Johnson RH, Smith AC, Spalding JMK, et al.  Effect of posture on blood-pressure in elderly patients. Lancet . 1965;;1:731-733.
29 +
Atkins D, Hanusa B, Sefcik T, et al.  Syncope and orthostatic hypotension. Am J Med . 1991;;91: 179-185.
30 +
Lipsitz LA, Storch HA, Minaker KM, et al.  Intra-individual variability in postural blood pressure in the elderly. Clin Sci . 1985;;69:337-341.
31 +
Lipsitz LA, Pluchino FW, Wei JY, et al.  Syncope in institutionalized elderly: the impact of multiple pathological conditions and situational stress. J Chronic Dis . 1986;;39:619-630.
32 +
Knopp R, Claypool R, Leonardi D.  The use of the tilt test in measuring acute blood loss. Ann Emerg Med . 1980;;9:72-75.
33 +
Fuchs SM, Jaffe DM.  Evaluation of the 'tilt test' in children. Ann Emerg Med . 1987;;16:386-390.
34 +
Gennari FJ.  Serum osmolality: uses and limitations. N Engl J Med . 1984;;310:102-105.
35 +
Weinberg AD, Pals JK, McGlinchey-Berroth R, et al.  Indices of dehydration among frail nursing home patients: highly variable but stable over time. J Am Geriatr Soc . 1994;;42:1070-1073.
36 +
McIntyre KM, Vita JA, Lambrew CT, et al.  A noninvasive method of predicting pulmonary-capillary wedge pressure. J Am Geriatr Soc . 1992;;327: 1715-1720.
37 +
Segal KR, Burastero S, Chun A, et al.  Estimation of extracellular and total body water by multiple-frequency bioelectrical-impedance measurement. Am J Clin Nutr . 1991;;54:26-29.
38 +
Hoffer EC, Meadow CK, Simpson DC.  Correlation of whole body impedance with total body water. J Appl Physiol . 1969;;27:531-534.
39 +
Lukaski HC, Johnson PE, Bolonchuk WW, et al.  Assessment of fat-free mass using bioelectrical impedance measurements of the human body. Am J Clin Nutr . 1985;;41:810-817.
40 +
Khaled MA, McCutcheon MJ, Reddy S, et al.  Electrical impedance in assessing human body composition: the BIA method. Am J Clin Nutr . 1988;; 47:789-792.
41 +
Guerrant RL, Weinberg AD, Glass RI, et al.  Dehydration and diarrhea in the elderly: a surmountable health challenge. Gerontologist . 1992;; 32:124-125.
42 +
Rocks BF, Sherwood RA, Cook JH.  Whole blood osmolality. Ann Clin Biochem . 1988;;23:106-108.
43 +
Weil MH, Michaels S, Klein D.  Measurement of whole blood osmolality. Am J Clin Pathol . 1982;; 77:447-448.
44 +
Weinberg AD.  Geriatric update: reimbursement controversies and trends in health care delivery to the elderly. Conn Med . 1987;;51:523-529.
45 +
National Research Council Subcommittee on the Tenth Edition of the RDAs. Recommended Dietary Allowances . 10th ed. Washington, DC: National Academy of Sciences; 1989;.
46 +
Pfeil LA, Katz PR, Davis PJ.  Water metabolism.  In: Morley JE, Glick Z, Rubenstein LZ, eds. Geriatric Nutrition . New York, NY: Raven Press Inc; 1990;:193-202.
47 +
Campbell SM.  Maintaining hydration status in elderly persons. Support Line . 1992;;14:7-10.
48 +
Carter JE, Gisolfi CV.  Fluid replacement during and after exercise in the heat. Med Sci Sports Exerc . 1989;;21:532-539.
49 +
Berger EY.  Nutrition by hypodermoclysis. J Am Geriatr Soc . 1984;;32:199-203.
50 +
Weinberg AD, Weinberg LL.  Guidelines and perspectives on the utilization of intravenous therapy in skilled nursing facilities. Conn Med . 1984;; 48:535-539.
51 +
Weinberg AD, Pals JK, Levesque PG, et al.  Dehydration and death during febrile episodes in the nursing home. J Am Geriatr Soc . 1994;;42:968-971.
52 +
Kim DE, Berlowitz DR.  The limited use of routine laboratory assessments in severely impaired nursing home residents. JAMA . 1994;;272:1447-1452.
53 +
Emanuel EJ.  A review of the ethical and legal aspects of terminating medical care. Am J Med . 1988;;84:291-301.
54 +
Lynn J, Childress JF.  Must patients always be given food and water? Hastings Cent Rep . 1983;; 13:17-21.
55 +
Micetich KC, Steinecker PH, Thomasma DC.  Are intravenous fluids morally required for a dying patient? Arch Intern Med . 1983;;143:975-978.
56 +
Siegler M, Weisbard AJ.  Against the emerging stream: should fluids and nutritional support be discontinued? Arch Intern Med . 1985;;145:129-131.
57 +
Meilaender G.  On removing food and water: against the stream. Hastings Cent Rep . 1984;;14: 11-13.
58 +
Council on Ethical and Judicial Affairs, American Medical Association.  Decisions near the end of life. JAMA . 1992;;267:2229-2233.
59 +
Council on Ethical and Judicial Affairs, American Medical Association.  Decisions to forgo life-sustaining treatment for incompetent patients. Code of Medical Ethics Reports . 1991;;II(No. (2) ):65-77.
60 +
Council on Ethical and Judicial Affairs, American Medical Association.  Withholding or withdrawing life-prolonging medical treatment. Code of Medical Ethics Current Opinions . 1992;;14-15.
61 +
McCann RM, Hall WJ, Groth-Juncker A.  Comfort care for terminally ill patients: the appropriate use of nutrition and hydration. JAMA . 1994;;272: 1263-1266.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Lavizzo-Mourey R, Johnson J, Stolley P.  Risk factors for dehydration among elderly nursing home residents. J Am Geriatr Soc . 1988;;36:213-218.
2 +
Daley J. Medicare Discharge Data, 1984-1987 . Brockton, Mass: Health Services Research and Development, Brockton/West Roxbury Veterans Affairs Medical Center; July 1993;.
3 +
Office of Research and Demonstration. Medicare and Medicaid Data Book, 1988 . Baltimore, Md: US Dept of Health and Human Services; 1988;: 37. Health Care Financing Adminstration publication 03270.
4 +
Vital and Health Statistics from the Centers for Disease Control and Prevention/National Center for Health Statistics. Detailed Diagnoses and Procedures, National Hospital Discharge Survey 1991 . Washington, DC: US Dept of Health and Human Services; February 1994;.
5 +
Health Care Financing Review. Medicare and Medicaid Statistical Supplement, 1992 Annual Supplement . Washington, DC: US Dept of Health and Human Services, Health Care Financing Administration, Office of Research and Demonstrations; October 1993;, vol 63. Health Care Financing Administration publication 0334.
6 +
Mahowald JM, Himmelstein DU.  Hypernatremia in the elderly: relation to infection and mortality. J Am Geriatr Soc . 1981;;29:177-180.
7 +
Long CA, Marin P, Bayer AJ, et al.  Hypernatremia in an adult in-patient population. Postgrad Med J . 1991;;67:643-645.
8 +
Himmelstein Du, Jones AA, Woolhandler S.  Hypernatremic dehydration in nursing home patients: an indicator of neglect. J Am Geriatr Soc . 1983;;31: 466-471.
9 +
6.2 CFR §483.25.
10 +
Adams F.  How much do elders drink? Geriatr Nurs . 1988;;9:218-221.
11 +
Gaspar PM.  What determines how much patients drink? Geriatr Nurs . 1988;;9:221-224.
12 +
Phillips PA, Roll BJ, Ledingham JG, et al.  Reduced thirst after water deprivation in healthy elderly men. N Engl J Med . 1984;;311:753-759.
13 +
Phillips PA, Bretherton M, Johnston CI, et al.  Reduced osmotic thirst in healthy elderly men. Am J Physiol . 1991;;261:R166-R171.
14 +
Silver AJ.  Aging and risks for dehydration. Cleve Clinic J Med . 1990;;57:341-344.
15 +
Crane MG, Harris JJ.  Effect of aging on renin activity and aldosterone excretion. J Lab Clin Med . 1976;;87:947-959.
16 +
Kirkland J, Lye M, Goddard F, et al.  Plasma arginine vasopressin in dehydrated elderly patients. Clin Endocrinol . 1984;;20:451-456.
17 +
Phillips PA, Johnston CI, Gray L.  Disturbed fluid and electrolyte homeostasis following dehydration in elderly people. Age Ageing . 1993;;22:S26-S33.
18 +
Rowe JW.  Renal system.  In: Rowe JW, Besdine RW, eds. Health and Disease in Old Age . Boston, Mass: Little Brown & Co; 1982;:165-183.
19 +
Silver AJ, Morley JE.  Role of the opioid system in the hypodipsia associated with aging. J Am Geriatr Soc . 1992;;40:556-560.
20 +
Wei JY, Gersh BJ.  Heart disease in the elderly. Curr Prob Cardiol . 1987;;12:1-65.
21 +
Luft FC, Weinberger MH, Grim CE, et al.  Sodium sensitivity in normotensive human subjects. Ann Intern Med . 1983;;98:758-762.
22 +
Rowe JW, Andres R, Tobin JD, et al.  The effect of age on creatinine clearance in men: a cross sectional and longitudinal study. J Gerontol . 1976;;31: 155-163.
23 +
Weinberg AD, Pals JK.  Assessment and treatment of dehydration in long-term care patients. Top Geriatr Med Nurs Home Care . 1993;;8:1-4.
24 +
Hoffman NB.  Dehydration in the elderly: insidious and manageable. Geriatrics . 1991;;46:35-38.
25 +
Pals JK, Weinberg AD, Beal LF, et al.  Clinical triggers for detection of fever and dehydration: implications for long-term care nursing. J Gerontol Nurs . 1995;;21:13-19.
26 +
Gross CR, Lindquist RD, Woolley AC, et al.  Clinical indicators of dehydration severity in elderly patients. J Emerg Med . 1992;;10:267-274.
27 +
Wandel JC.  The use of postural signs in the assessment of fluid volume status. J Prof Nurs . 1990;;6:46-54.
28 +
Johnson RH, Smith AC, Spalding JMK, et al.  Effect of posture on blood-pressure in elderly patients. Lancet . 1965;;1:731-733.
29 +
Atkins D, Hanusa B, Sefcik T, et al.  Syncope and orthostatic hypotension. Am J Med . 1991;;91: 179-185.
30 +
Lipsitz LA, Storch HA, Minaker KM, et al.  Intra-individual variability in postural blood pressure in the elderly. Clin Sci . 1985;;69:337-341.
31 +
Lipsitz LA, Pluchino FW, Wei JY, et al.  Syncope in institutionalized elderly: the impact of multiple pathological conditions and situational stress. J Chronic Dis . 1986;;39:619-630.
32 +
Knopp R, Claypool R, Leonardi D.  The use of the tilt test in measuring acute blood loss. Ann Emerg Med . 1980;;9:72-75.
33 +
Fuchs SM, Jaffe DM.  Evaluation of the 'tilt test' in children. Ann Emerg Med . 1987;;16:386-390.
34 +
Gennari FJ.  Serum osmolality: uses and limitations. N Engl J Med . 1984;;310:102-105.
35 +
Weinberg AD, Pals JK, McGlinchey-Berroth R, et al.  Indices of dehydration among frail nursing home patients: highly variable but stable over time. J Am Geriatr Soc . 1994;;42:1070-1073.
36 +
McIntyre KM, Vita JA, Lambrew CT, et al.  A noninvasive method of predicting pulmonary-capillary wedge pressure. J Am Geriatr Soc . 1992;;327: 1715-1720.
37 +
Segal KR, Burastero S, Chun A, et al.  Estimation of extracellular and total body water by multiple-frequency bioelectrical-impedance measurement. Am J Clin Nutr . 1991;;54:26-29.
38 +
Hoffer EC, Meadow CK, Simpson DC.  Correlation of whole body impedance with total body water. J Appl Physiol . 1969;;27:531-534.
39 +
Lukaski HC, Johnson PE, Bolonchuk WW, et al.  Assessment of fat-free mass using bioelectrical impedance measurements of the human body. Am J Clin Nutr . 1985;;41:810-817.
40 +
Khaled MA, McCutcheon MJ, Reddy S, et al.  Electrical impedance in assessing human body composition: the BIA method. Am J Clin Nutr . 1988;; 47:789-792.
41 +
Guerrant RL, Weinberg AD, Glass RI, et al.  Dehydration and diarrhea in the elderly: a surmountable health challenge. Gerontologist . 1992;; 32:124-125.
42 +
Rocks BF, Sherwood RA, Cook JH.  Whole blood osmolality. Ann Clin Biochem . 1988;;23:106-108.
43 +
Weil MH, Michaels S, Klein D.  Measurement of whole blood osmolality. Am J Clin Pathol . 1982;; 77:447-448.
44 +
Weinberg AD.  Geriatric update: reimbursement controversies and trends in health care delivery to the elderly. Conn Med . 1987;;51:523-529.
45 +
National Research Council Subcommittee on the Tenth Edition of the RDAs. Recommended Dietary Allowances . 10th ed. Washington, DC: National Academy of Sciences; 1989;.
46 +
Pfeil LA, Katz PR, Davis PJ.  Water metabolism.  In: Morley JE, Glick Z, Rubenstein LZ, eds. Geriatric Nutrition . New York, NY: Raven Press Inc; 1990;:193-202.
47 +
Campbell SM.  Maintaining hydration status in elderly persons. Support Line . 1992;;14:7-10.
48 +
Carter JE, Gisolfi CV.  Fluid replacement during and after exercise in the heat. Med Sci Sports Exerc . 1989;;21:532-539.
49 +
Berger EY.  Nutrition by hypodermoclysis. J Am Geriatr Soc . 1984;;32:199-203.
50 +
Weinberg AD, Weinberg LL.  Guidelines and perspectives on the utilization of intravenous therapy in skilled nursing facilities. Conn Med . 1984;; 48:535-539.
51 +
Weinberg AD, Pals JK, Levesque PG, et al.  Dehydration and death during febrile episodes in the nursing home. J Am Geriatr Soc . 1994;;42:968-971.
52 +
Kim DE, Berlowitz DR.  The limited use of routine laboratory assessments in severely impaired nursing home residents. JAMA . 1994;;272:1447-1452.
53 +
Emanuel EJ.  A review of the ethical and legal aspects of terminating medical care. Am J Med . 1988;;84:291-301.
54 +
Lynn J, Childress JF.  Must patients always be given food and water? Hastings Cent Rep . 1983;; 13:17-21.
55 +
Micetich KC, Steinecker PH, Thomasma DC.  Are intravenous fluids morally required for a dying patient? Arch Intern Med . 1983;;143:975-978.
56 +
Siegler M, Weisbard AJ.  Against the emerging stream: should fluids and nutritional support be discontinued? Arch Intern Med . 1985;;145:129-131.
57 +
Meilaender G.  On removing food and water: against the stream. Hastings Cent Rep . 1984;;14: 11-13.
58 +
Council on Ethical and Judicial Affairs, American Medical Association.  Decisions near the end of life. JAMA . 1992;;267:2229-2233.
59 +
Council on Ethical and Judicial Affairs, American Medical Association.  Decisions to forgo life-sustaining treatment for incompetent patients. Code of Medical Ethics Reports . 1991;;II(No. (2) ):65-77.
60 +
Council on Ethical and Judicial Affairs, American Medical Association.  Withholding or withdrawing life-prolonging medical treatment. Code of Medical Ethics Current Opinions . 1992;;14-15.
61 +
McCann RM, Hall WJ, Groth-Juncker A.  Comfort care for terminally ill patients: the appropriate use of nutrition and hydration. JAMA . 1994;;272: 1263-1266.

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