Dehydration and Malnutrition in Nursing Homes

Nursing home dehydration and malnutrition are serious and deadly threats to older people.  When nursing homes are understaffed or careless with resident health, dehydration can set in all too quickly.

Support with Eating and Drinking is Critical to Resident Safety

One of the most critical parts of our surviving, and thriving, is having adequate intake of nutritious food and sufficient water.  As we age, our ability to endure too little food or water decreases.  We’re also more susceptible to injuries from too little food or water—bedsores, kidney failure, shock, and death.

Nursing home residents often need assistance with eating and drinking, including having the correct balance of nutrients for their needs, being encouraged to eat or drink, physical assistance eating or drinking, or even taking food, fluid, and medicine other than by mouth, such as a PEG tube into the stomach.

Nursing homes are required to ensure residents who require assistance or have cognitive issues receive adequate food and fluid every day.  Often, this is left to aides (nursing assistants or STNAs), who are overworked, understaffed, and underpaid.  The results can be sickness, shock, even death.

What are the Signs and Symptoms of Nursing Home Dehydration?

You cannot assume someone will say, “I’m thirsty” to indicate they need more fluid.  Thirst may not be a reliable early indicator of an older person’s need for water.  Particularly older adults may become dehydrated before becoming thirsty.  And some older adults may not be able to communicate their thirst reliably to busy care providers.

So you need to be on the lookout.

Signs of minor or moderate dehydration include:

• Increased thirst.
• Dry mouth.
• Tired or sleepy.
• Decreased urine output.
• Urine is low volume and more yellowish than normal.
• Headache.
• Dry skin.
• Dizziness.

Signs of extreme dehydration may include:

• Extreme thirst
• Loss of appetite
• Dry or ashy skin
• Dark-colored urine
• Feeling faint, dizzy, or light-headed
• Chills
• Facial skin feeling flushed and red
• Seizures
• Labored breathing
• Vomiting

Remember, though, “thirst” may never show up.  Either because the thirst reflex is reduced, or the person is unable to recognize or communicate it to caregivers.

Are older People at Greater Risk for Dehydration or Malnutrition?

Older people are at increased risk for dehydration.  As we get older, “your body’s fluid reserve becomes smaller, your ability to conserve water is reduced and your thirst sense becomes less acute.”   (Mayo Clinic)  I would add the risks of dehydration become much sharper: faster organ shut down, more complications, bedsores and infections.  And an older person is much more likely to be unable to fend for themselves or summon help.

Older people are much more likely to have chronic illnesses that can cause or become worse with dehydration, too.  Uncontrolled or untreated diabetes increases the risk o dehydration.  So does kidney disease.  medications that increase fluid output in urine–diuretics like Lasix, that may be used to treat congestive heart failure–also increase the risk of dehydration.

Simply not feeling well, or having cognitive or memory issues, can lead to decreased eating and drinking. (Food is a major source of fluids, too, so that’s double trouble when you do not eat well.)

Medical Diagnoses Showing Dehydration

When someone is extremely dehydrated due to lack of water their blood salt (sodium) levels become extremely concentrated.  This is called hypernatremia (hyper:  over; natremia: presence of sodium in the blood).  Hypernatremia is elevated sodium level in the blood, specifically a serum level above 145 mEq/L.  This dangerously high sodium level is normally caused by too little water, not too much salt, especially in the elderly population.

Hypernatremic dehydration in nursing home patients is an indicator of neglect.

Extreme dehydration leads to kidney failure, shock, mutli-organ failure, and death.

In one case, we represented the family of a woman who was dehydrated to the point of shock in just under two weeks at a nursing home.  She died a few months later.  The difference in her appearance and health was startling.

If you would like to discuss your loved one’s situation, injuries, or death at a nursing home, call us at 216-777-8856.

What are the Signs and Symptoms of Nursing Home Malnutrition?

Signs of malnutrition include:

• Severe, rapid, un-planned/unexplained weight loss
• Poorly healing wounds
• Very easy bruising
• Dental problems
• Red, inflamed eyes
• Confusion / inability to answer simple questions
• Sudden memory problems
• Yellowing of the skin
• Muscle twitches and loss of muscle mass
• Infections or canker sores in the mouth
• Diarrhea
• Goiter

Many of these symptoms mirror or can be related to other medical conditions.  That can make it difficult to spot nutrition as the issue unless blood work is being done, or a nutritionist / dietitian or doctor observes the issues and figures it out.

If someone is being neglected  by staff, you cannot rely on that same staff to notice the changes in the resident their neglect is causing.  At least not until it may be too late.

There are also secondary risks to nutrition problems.  For example, a 2013 study showed that malnutrition resulted in an increased risk of other dangers, like falls.[i]

If you would like us to review a situation involving your loved one’s injury or death due to dehydration or other nursing home neglect or abuse, you can call us at 216-777-8856, or fill out the contact form on this page (here).  Inquiries are confidential, cost nothing, and we will take the time to answer your questions.

Facts about Malnutrition and Dehydration in the Elderly in Nursing Homes

The National Consumer Voice for Quality Long Term Care recently published a helpful fact sheet regarding nursing homes/ long term care facilities and malnutrition and dehydration.  They stress the importance of proper nutrition and aging. This is something that nursing homes are well aware of and are actually required by law to monitor.

They outline the following facts:

NUTRITION AND THE NURSING HOME REFORM ACT OF 1987

Nursing homes are required by law to assess the nutritional needs of their residents at least every three months. Still, they report that 40% of nursing home residents are malnourished.

CAUSES OF MALNUTRITION AND DEHYDRATION IN NURSING HOMES

Physical and psychological causes: illness, especially congestive heart failure, chronic lung diseases, and kidney diseases; adverse drug effects, such as nausea, vomiting, diarrhea, cognitive disturbances, or sleepiness; food and drug interactions, which decrease the ability of the body to absorb vitamins and minerals; depression and loneliness; swallowing disorders, mouth problems, such as tooth loss, dentures that do not fit properly, mouth sores, and mouth pain; and tremors, dementia, or agitation which affect the residents’ ability to feed themselves.

ENVIRONMENTAL CAUSES

  including inadequate attention from staff for residents who need assistance eating; lack of individualized care, as many residents may lose their appetites from a lack of exercise, exposure to fresh air, or sensory or mental stimulation; staff who are uneducated about proper ways to assist residents with eating and drinking, including proper positioning; reliance on liquid supplements instead of making sure residents eat enough food to get the vitamins and minerals they need; special diets or pureed food, which are often unappetizing or regular food that is served cold; cultural differences that occur when the nursing facility does not serve foods that a resident is accustomed to eating; an unpleasant, chaotic dining room environment, which distracts residents and increases agitation; tube feedings not being administered; absence of fresh water within reach at the bedside and failure to open cartons of milk, juice, and the supplements that are left out of reach; and not providing oral health care prior to meals.

PINPOINTING THE PROBLEM

The facts presented offer the following questions to help identify malnutrition:

Does s/he: Seem to be losing weight? Have clothes that fit more loosely than Usual? Have dry, cracked lips or a pale-looking mouth? Have difficulty speaking due to a dry mouth? Often complain of thirst and ask for water? Urinate infrequently and have dark yellow urine? Have skin that feels dry and warm to the touch? Have a dry, bright red, and furrowed tongue? Complain that her false teeth no longer fit? Have any mouth tenderness, sores or tooth loss? Have thinning hair or hair that is growing sparser? Have wounds that seem to take longer to heal? Appear weak or disoriented? Have skin that is breaking down or seems loose and looks or feels drier than usual?

WHAT SHOULD YOU DO?

The National Consumer voice recommends the following steps:

Determine if your loved one can feed themselves. Also, check to see if they are being allowed to eat their meals when they would like to do so, or do they need assistance eating? Check to see if the staff is monitoring your loved one’s weight in order to notice a change.

Share. Tell the staff at the nursing home what you have found. Share your observations about weight and signs of malnutrition and dehydration.

Ask. Ask for a meeting with nursing home administrators to help ensure your loved one gets the help and assistance they need to be nourished. Ask questions. Make sure they are aware of your concerns for your loved one’s safety.

Talk with those who are caring for your loved one. Talk to the nurses, CNAs, and physicians. Share your concerns and make suggestions. You know your loved one best!

Continue to monitor your loved one and make sure they are safe. If these do not work, you may need to contact a nursing home abuse lawyer and your local nursing home monitoring agency.

You can find more information from the National Consumer Voice for Quality Long Term Care here.

Are Nutrition and Dehydration in Nursing Homes Related?

Neglect, inadequate staffing, and lack of professional supervision are common themes linking nursing home dehydration and malnutrition.

Making sure residents eat and drink enough often fall on the same people in a nursing home: nursing aides, dietitians, nursing supervisors (if alerted to a problem).   When caregivers or the nursing home system fails, it can cause both nutrition and dehydration issues.  And if someone is weak from dehydration, they may not be able to eat.  One can follow the other.

Medical studies suggest one reason for dehydration in nursing homes is inadequate staffing and lack of professional supervision, issues that can lead to malnutrition, too.  Kayser-Jones J, Schell ES, Porter C, Barbaccia JC, Shaw H.

In one study, 39 out of 40 nursing home residents that were observed received inadequate amounts of fluids during each of the days that they were followed.  Journal of American Geriatric Society at J Am Geriatr Soc. 1999 Oct;47(10):1187-94.

That is shocking.  The authors concluded:

When staffing is inadequate and supervision is poor, residents with moderate to severe dysphagia, severe cognitive and functional impairment, aphasia or inability to speak English, and a lack of family or friends to assist them at mealtime are at great risk for dehydration. Adequate fluid intake can be achieved by simple interventions such as offering residents preferred liquids systematically and by having an adequate number of supervised staff help them to drink while properly positioned.

In one case I handled, a nursing home  caused a woman to become severely dehydrated in just 2 weeks.  She was in the nursing home for care while the home caregiver was away, called “respite care.”  When the family returned to pick her up, she looked so bad they asked the facility to call 911. The facility refused, saying she was just “sleepy,” a red flag for dehydration.  So her family drove her to the emergency room, where she was found to be in shock.  She never returned to health.

In her case, the dehydration likely led to decreased appetite and ability to feed herself, causing the malnutrition.  All because of neglect.

If you would like us to review a situation involving your loved one’s injury or death due to dehydration or other nursing home neglect or abuse, you can call us at 216-777-8856, or fill out the contact form on this page (here).  Inquiries are confidential, cost nothing, and we will take the time to answer your questions.

Is Nursing Home Dehydration and Malnutrition Negligence?

There are conditions that can cause dehydration or cause issues with nutrition that are not nursing home negligence.  An infection leading to sepsis could cause extreme dehydration and shock.  Assuming the nursing home did not fail to recognize or seek treatment for the infection, there may not be negligence.

More often, however, neglect or other negligence may be a cause.

Ignoring Medication-Related Dehydration

Dehydration is more common in the elderly for a number of reasons.  A number of medications can cause dehydration by increasing fluid excretion in the urine (diuretics).  Sometimes, that is a side effect.  Sometimes, that is the point, such as to reduce fluids for someone with congestive heart failure.

Nursing homes are required to account for medications and other factors that could lead to dehydration.  They still must ensure adequate intake for at-risk residents.  Just because someone is on a diuretic does not mean they can be left to dehydrate and die.

Nursing homes that are regularly understaffed or not adequately training and supervising staff to meet the specific needs of each resident will eventually harm residents, possibly through medication errors, dehydration, malnutrition, or neglect.  Understaffing and inexperience puts many residents at risk of dehydration.

Inadequate Provision of Fluids or Assistance

Fluid intake for the elderly at nursing homes is imperative.  Nursing home residents become dehydrated in many cases because of inadequate nursing home staffing, because staff do not have the time to ensure every resident’s care needs are met.

Meal trays and drinks are left without monitoring intake or assisting with eating or drinking.   Lack of adequate nursing supervision contributes to nursing home resident dehydration.  Sometimes staff falsely document they provided help.  Sometimes they just leave it blank.

Failing to Respond to Dehydration in Time

Whatever the cause of dehydration or malnutrition, it is the nursing home’s job to recognize it and respond.

Allowing dehydration to start, failing to recognize early signs, and failing to intervene will lead to medical emergencies like kidney failure, low blood pressure which can harm other organs, electrolyte abnormalities like sodium, potassium and chloride, which can lead to organ damage or shock, coma, and death.

Severe dehydration is a medical emergency.  Symptoms include confusion, weakness, severe thirst, lack of thirst response, dry mouth, being unusually tired or sleepy, decreased urine output, dark colored urine, headache, dry skin, and dizziness. [ii]   It can also include urinary tract infections, pneumonia and bed sores in bed-bound patients.

Federal and state regulations require nursing homes to recognize and respond to these types of changes.  When a nursing home fails to meet Ohio and / or Federal rules and regulations governing caring for the elderly, the nursing home may be held liable for all resulting damages.

Should I Sue the Nursing Home for Dehydration or Malnutrition?

You should sue a nursing home for dehydration or malnutrition when:

1. the nursing home caused the injury by carelessness; and
2. the injury is significant, or caused the resident’s death as a result.

Careless, or “unreasonable,” care can include causing the problem through neglect.  Carelessness can also include not responding to symptoms of dehydration in time.

The injury has to be significant or deadly to support the damages that will make a difference to the nursing home in future care.  And to justify the costs of a lawsuit.  When nursing home corporations profit off unsafe understaffing, the only thing that will change that is getting hit in the bank account.

That is not to say the nursing home should not be investigated just because the injured person recovers well.  You should still report the issue through a complaint to the state government.   We can help you contact the right agencies to file such a complaint.

How do you know if the injuries were caused by carelessness?  Have a nursing home abuse lawyer investigate.  That’s our job.  Don’t trust the nursing home to come clean about what they did wrong.  I’ve never seen that happen.  but also understand, there may be proper care, but a bad outcome for a resident.  By looking at the medical records speaking with the care providers, and consulting with experts, I can help you find out if this was carelessness–“negligence”–or not.

How do you know if the injuries and damages are sufficient to support a lawsuit?  Have a nursing home abuse lawyer investigate.  That’s our job.

If you would like us to review a situation involving your loved one’s injury or death due to dehydration or other nursing home neglect or abuse, you can call us at 216-777-8856, or fill out the contact form on this page.  Inquiries are confidential, cost nothing, and we will take the time to answer your questions.

Dehydration and the Elderly

Dehydration is a particular concern for older people because of how quickly dehydration can affect other health issues they may have.  Dehydration can mimic other disease processes, too.  And make them worse.  This means you may never be told the real reason for their decline or death was dehydration.  The nursing home wants to blame the medical conditions the dehydration caused or made worse, so they can claim that the death is not their fault.

How much water should an older person drink a day?

Research suggests nursing homes should make sure an older person drinks at least 1500 ml a day (a little over 6 cups), adjusted to their particular health needs and medications.  The old “drink 8 glasses of water a day” is not based on scientific research.  Also, food intake provides a lot of fluid–which means if someone eats less, they may be getting too little fluid.

So what are some of the things that should cause a nursing home to adjust fluid intake?

Medical conditions that cause fever, diarrhea, or vomiting, resulting in more lost fluids that must be replaced to avoid dehydration.   That’s obvious to most people.  Believe it or not, some nursing homes may not recognize the need to react to these conditions to prevent dehydration.

Other conditions can also lead to increased fluid loss, or decreased fluid consumption.  Bladder or urinary tract infections (“UTIs”) infections, kidney or urinary tract stones, infections generally, confusion, decreased appetite, can all lead to dehydration.  (Worse, dehydration can be a vicious cycle.  You become confused from moderate dehydration.  Confusion makes you unable to take in enough water yourself.  Making you more dehydrated.)

There are also conditions that cause a person to retain fluid in a dangerous way.  Some conditions, such as heart failure and some types of kidney, liver and adrenal diseases, may cause a person to retain fluids in a dangerous way.  Doctors might need to limit fluid intake, or use drugs that help people lose fluids, to treat the condition.  It can be a balancing act.

Nursing staff should recognize these issues and report them to supervisors and physicians so they can address the situation.

There are many steps that can be taken to re-hydrate someone:

• simple encouragement to drink more water or sports-like drinks to speed rehydration
• Fluids through a tube through the person’s nose into the stomach (a naso-gastric tube)
• Direct re-hydration through saline solution into the blood through an IV

Nursing staff and physicians need to work together to implement the right interventions to prevent, halt, or reverse dehydration early.

 Can dehydration cause confusion?

Dehydration can cause mild and extreme confusion in an older person.  Moderate dehydration can cause temporary confusion that may reverse with proper care.  There is a physiological breakdown of brain functioning with extreme dehydration that is irreversible.  It is brain damage.  (Other organs can be permanently damaged as well, including the heart and kidneys.)

Dehydration can also cause or make worse other conditions that cause confusion.  This includes infections like urinary tract infections and pneumonia.

Can Dehydration Cause Death?

Dehydration can cause death for anyone, but especially older people.

Dehydration can cause kidney shutdown or failure. As we age, kidney function can be impaired or less able to restore itself once damaged. Becoming dehydrated can make someone more confused, leading to lack of eating and drinking, agitation, falls, and other injuries.

Extreme dehydration can cause shock–the body systems shut down–leading to respiratory failure and death. Dehydration can make you more susceptible to infections that cause death.

If you would like us to review a situation involving your loved one’s injury or death due to dehydration or other nursing home neglect or abuse, you can call us at 216-777-8856, or fill out the contact form on this page (here).  Inquiries are confidential, cost nothing, and we will take the time to answer your questions.

 What if a Nursing Home Resident Refuses to Drink Fluids?

It is never a nursing home resident’s fault they become dehydrated.  But nursing homes may claim the person refused to drink.  Or that they had to “respect the choice” of a person who does not eat or drink enough.

That’s hogwash.

Dehydration can cause confusion and bad decision making.  Just because someone you let become dehydrated is confused or agitated and hard to convince to drink does not mean you let them die of dehydration.

If you really cannot get someone to drink because they are confused, that’s a medical emergency.  They need to be in the hospital, where they can be treated with IV fluids and their confusion can be addressed.

Sometimes residents avoid fluids because of incontinence.  Urinary incontinence should be managed properly.  Residents will be less likely to avoid fluids if they are regularly and respectfully provided toileting opportunities as needed.  Instead of being left to wet or soil themselves in an understaffed facility.  Again, that is no the resident’s fault that they want to have dignity.

How Can Nursing Homes Prevent Dehydration?

Nursing homes can prevent dehydration in the elderly by first ensuring adequate fluid intake.  This requires education, training, encouragement, monitoring, and reaction.

Educating on the risks of dehydration

Educating and raising awareness among nursing home residents, their families, and caregivers, of how important preventing dehydration is to their safety is critical.   And too often overlooked.   Healthcare providers agree.  In one study, 89% of American healthcare providers considered that educating and making the elderly aware is a key strategy to preventing dehydration. (Abdallah et al. 2009).

Encouraging Fluid Intake

The elderly should be encouraged to consume fluids to prevent dehydration according to multiple studies.  Some proposed strategies include:

• Offer fluids regularly during the day
• Provide liquids readily available all day (at bedside or chairside in geriatric institutions) by placing containers such as small bottles of water or sippy cups
• Encourage consumption of fluids with medication Provide preferred beverages
• Prescribe and ensure a minimum intake of 1.5 litres, in periods of increasing risk for dehydration

(source: Faes 2007; Bennett 2000; as reported by http://www.h4hinitiative.com.)

Monitoring Fluids and Detecting Dehydration

Nursing homes can and should monitor resident fluid intake and output.

Monitoring fluid intake means writing down how much fluid a person drinks during the course of a day.  If there are adequate nursing staff, they should be able to see and write down in the medical chart how much a person drinks of each beverage offered.

For example, at meals a certain amount of water is given.  When the meal is cleared, how much of the fluid the person drank is recorded.  This can result in recognizing dehydration from reduced fluid intake before there are any other symptoms.

On the other hand, monitoring fluid output means monitoring urination (either when toileting, or changing), and other major losses like diarrhea or vomiting.

Problems come in because many nursing homes do not provide adequate staff to chart input and output.  They’re too busy, so they miss important early warning signs.

Signs of dehydration in the elderly nursing homes must be aware of and monitor for include:

Reacting to Dehydration Risks

Besides the risks associated with decreased drinking, or increased output, there are other risk factors. Nursing homes have to be aware that when someone is on certain medications (such as diuretics like Lasix), they lose much more fluid.  That has to be made up for with intake.  Nursing homes have to recognize the dehydration risks for someone with an infection or fever.  All of this has to be accounted for when providing fluids and encouragement.

Reacting to Early Dehydration Warning Signs

Dehydration can be treated more easily the earlier it is discovered.

It does not matter why someone is becoming dehydrated.  If the nursing home ignores the early warning signs, they are responsible for the harm that results.

Once someone has become severely dehydrated, they may never recover.  Even though they may survive for weeks or even months, severe dehydration can cause them to spiral down to death. Organs are damaged: the kidneys, the heart, the lungs.  The person may be unable to return to their prior strength.  They may become bed bound, lose cognitive ability, or immune system strength.  They may suffer from bedsores or other skin breakdowns that become infected or won’t heal.

How Can I Help an Older Person Stay Hydrated?

Family members can take the same approach to help prevent dehydration in the elderly: education, training, encouragement, monitoring, and reaction.

The editorial staff at Daily Caring put together a great list of 6 ideas to get seniors to stay hydrated that are simple, practical, and seem, to me, to be effective.  Here they are:

1. Remember there are many sources of fluids

Older adults don’t have to drink only plain water to get hydrated. Coffee, tea, fruit juice, sweetened beverages, fruits, and vegetables all contain water. If your senior really hates drinking fluids, serve them more foods with high water content to increase their hydration.

2. Keep water easily accessible

Sometimes, making it easy for seniors to serve themselves could encourage them to drink more water. Try putting a lightweight pitcher of water and a cup near their favorite seat.

3. Experiment with beverages at different temperatures

Your senior may prefer hot drinks to cold, or the other way around. Experiment to find out which type they like better. Try warming up juices, making decaf iced coffee with cream, or adding soda water to make drinks bubbly.

4. Try something savory

Those who like savory foods may enjoy drinking hot soup broth. The broth can come from a can, box, or powder, but some older adults really like it – especially in cold weather.

5. Make popsicles

Homemade popsicles made from fruit juice or a mix of juice and water are a great summer treat. But they’re also a great way to get fluids into your senior.

6. Offer smoothies, milkshakes, Ensure, sports drinks

Some stubborn older adults may really resist drinking fluids. If so, you can try enticing them with smoothies, milkshakes, Ensure, or sports drinks. Sometimes they’ll like the flavor or texture and be willing to drink these beverages.

This is a great list.

Nursing Home Dehydration and Malnutrition Articles

Sources

[i] Malnutrition is associated with an increased risk of falls and impaired activity in elderly patients in Dutch residential long-term care (LTC): a cross-sectional study, Arch Gerontol Geriatr. 2013 Jan-Feb;56(1):265-9. doi: 10.1016/j.archger.2012.08.005. Epub 2012 Aug 29. Pubmed: https://www.ncbi.nlm.nih.gov/pubmed/22939947

[ii] Symptoms and Causes [of dehydration], Mayo Clinic Staff, http://www.mayoclinic.org/diseases-conditions/dehydration/symptoms-causes/dxc-20261072