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Dysphagia and Dehydration
The Speech Pathologist’s Role in to Improve Dehydration in the Elderly with Dysphagia
Speech-Language Pathologists play an important role in improving dehydration in patients with dysphagia. Dysphagia can frequently lead to dehydration, especially in the elderly. Dehydration means that the body does not have as much fluids as it should. It can be caused by not drinking enough fluids or losing too much fluid such as with vomiting/diarrhea.
The prevalence of oropharyngeal functional dysphagia is very high: it affects more than 30% of patients who have had a cerebrovascular accident; 52%–82% of patients with Parkinson’s disease; 84% of patients with Alzheimer’s disease, up to 40% adults aged 65 years and older, and more than 60% of elderly institutionalized patients (Clave, P., et. al, 2004; Elkberg, O., e. al, 2004) Sometimes, these patients may have both dysphagia and dehydration. Dehydration is one of the most common causes of hospitalization among elderly individuals who live in the community or long term care facilities.
Risks for dehydration:
Risks for dehydration are numerous in the elderly. A major risk factor is when a patient is on multiple medications. Many medications can cause dysphagia and reduce salivary flow. Patients with dry mouths and reduced salivation have difficulty chewing foods. Another factor is mobility. Elderly patients may not be able to get up to get a glass of water. They also may forget that they haven’t eaten/drank. These patients need to be offered food and drink, even if the patient is not asking for it.
Patients on modified diets also are at risk for dehydration. Patients with thickened fluids may be noncompliant because they dislike the thickened fluids and therefore the intake of fluids is minimal, leading to dehydration. The Frasier water protocol has been developed to help reduce dehydration and improve quality of life. Patients aspirating thin liquids, are allowed free water between meals. It was intended for those who are able to participate in three hours of physical therapy 6 times/week. Studies showed that these patients did not have a significantly higher risk of getting aspiration pneumonia.
One study, compared patients aspirating on thin liquids given free water to a control group who were not given free water. The patients were placed as aspirators only after a bedside swallow evaluation (not all underwent videofluroscopy). The patients who received the free water (14.3%) compared to the control group (no cases), suggested a causal relationship between aspiration of water and the development of lung complications including aspiration pneumonia(Karragianas, M., 2011). The water protocol should be used with caution on patients who are immobile with multiple medical conditions.
Consequences of dehydration:
Negative consequences of dehydration include changes in drug potency, trouble with healing from infections and wounds, urinary tract infections, constipation, confusion, lethargy, acute renal failure, and a malfunctioning cardiac system.
Lab Values indicating dehydration:
Speech-language pathologists should be mindful of laboratory values indicating dehydration. A patient with diabetes may have an elevated blood sugar level, which can cause sugar to spill over into the urine and adding water, results in dehydration. The condition is accompanied by frequent periods of urination. Electrolytes may be imbalanced or there can be a lack of potassium, sodium and chloride to help the body function properly. Check the BUN and Creatinine. High BUN and creatinine may suggest dehydration. The color and clarity of urine, the urine specific gravity (the mass of urine is compared with that of equal amounts of distilled water), and the presence of ketones (carbon compounds—a sign the body is dehydrated) in the urine may all help to indicate the degree of dehydration.
It is important to use a multidisciplinary approach to diagnosis and treatment of dysphagia and dehydration. If a person is losing weight or not eating as much, the speech-language pathologist can speak with the dietitian about the resident’s nutrition and hydration status. Together, collaborate in ways to improve dehydration.
Components of a Comprehensive Hydration Program:
1. Educate the staff and families on warning signs for dehydration and ways to prevent dehydration.
2. Estimate the patient’s fluid needs on initial assessment, quarterly, yearly and any significant changes.
3. Develop and maintain a comprehensive care plan that documents the resident’s dehydration risk factors, estimated fluid needs and an individualized plan for meeting fluid needs.
4. Establish a facility standard for the minimum amount of fluid served on meal trays each day and assure that residents receive adequate assistance at mealtime.
5. Provide a large water cooler at each nursing station and replenish with fresh cool water daily. Make sure that 10–12 oz cups are readily available (cup holders may be needed). Develop a procedure for how coolers are washed and sanitized.
6. Use 8oz cups to provide fluids at each medication pass.
7. Start systematic fluid passes by using a hydration cart at least twice daily and offer a variety of fluids. Use 10 -12oz cups and include fluid selections that are new for residents, such as tropical punches, caffeine free sodas and ethnic beverages that are favorites for your resident population.
8. Set up hydration stations in the Rehabilitation and Activities Departments.
9. Implement a visual system, such as a picture of a drop of water next to the resident’s name on his/her door, so that staff can easily identify residents at highest risk for dehydration.
10.Implement a mealtime and between meals fluid intake documentation system.
11. Establish a system for providing the facility’s Registered Dietitian (RD) and/or Diet Technician (DTR) with a copy of current hydration related laboratory values. The RD and/or DTR review the laboratory results, complete a timely assessment of the resident’s hydration status and update the resident’s hydration plan of care as needed.
12. Implement quality assurance monitoring of the Comprehensive Hydration Program.
References:
Clavé P, Terré R, de Kraa M, Serra M. Approaching oropharyngeal dysphagia. Revista Espanola de Enfermedades Digestivas. 2004;96(2):119–131. [PubMed]
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