JAMDA 16 (2015) 175e176
JAMDA journal homepage: www.jamda.com
Editorial
Dehydration is Difficult to Detect and Prevent in Nursing Homes Sandra M. Lima Ribeiro PhD a, John E. Morley MB, BCh b, * a b
Gerontology Division, School of Arts, Sciences and Humanities, University of Sao Paulo, Sao Paulo, Brazil Divisions of Geriatric Medicine and Endocrinology, Saint Louis University School of Medicine, St. Louis, MO
“One should know that living beings are moist and warm .however old age is dry and cold”wAristotle The ancient Greeks, as attested to not only by Aristotle, but also by Homer, who compared old age with a dried olive branch, and Galen, who saw a major feature of aging as a loss of body water, perceived dehydration to be a central part of aging. The reality of this concept is further recognized by 2 recent articles in our Journal, examining the problems of maintaining fluid intake in residents in the nursing home.1,2 Dehydration is a failure to maintain adequate amounts of body water because of either poor fluid intake or pathologic loss of body fluids.3,4 Dehydration is associated with frailty, poor cognition, falls, delirium, disability, and mortality.5e15 Dehydration is a major cause of decreased attention and fluctuating mental status, the hallmarks of delirium, in the nursing home.12e15 In nursing homes, dehydration has been considered to be present in 0.8% to 1.4% of persons.16 A single nursing home study where dehydration was carefully looked for, suggested that the 6-month incidence of dehydration was as high as 1 in 3.17 In a nursing home in Taiwan, 45% of residents had a fluid intake below their estimated requirements.18 In hospitalized older persons, dehydration was present in 7.8%.19 The clinical diagnosis of dehydration is an underestimation compared with dehydration present as determined by bioelectrical impedance.20 Bioelectrical impedance suggests a high prevalence of dehydration in persons with end-stage Alzheimer’s disease.21 However, it needs to be noted that the accuracy of bioelectrical impedance at determining dehydration during rapid shifts of water between body compartments has been questioned. This questioning depends on the type of device (single or multifrequency) or on the type of analysis (predictive equations, vector analysis, or other).22e25 There are a number of reasons why older persons are at increased risk of water-loss dehydration. One of the most important is that as older persons become dehydrated, they fail to develop thirst at the same rate as younger persons.26 This appears, in part, to be due to alterations in angiotensin and in opioid neurotransmitters ability to modulate thirst with age.27,28 There is a decline in the kidney to retain fluid with aging, perhaps related to a decrease in vasopressin 2 receptors and aquaporins (water channels).29,30 Sarcopenia is the loss of The authors declare no conflicts of interest. * Address correspondence to John E. Morley, MB, BCh, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S Grand Blvd, M238, St. Louis, MO 63104. E-mail address: [email protected] (J.E. Morley). http://dx.doi.org/10.1016/j.jamda.2014.12.012 1525-8610/Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
muscle mass associated with aging.31e34 Muscle is the major water storage organ in the body.31 Thus, older persons have a lower fluid reserve than younger people. Other reasons for dehydration in older persons is the increased prevalence of diabetes mellitus that leads to fluid diuresis,35e38 the increase of polypharmacy and particularly diuretics to treat ankle edema,39e41 and excess sweating and hyperventilation because of infections or chronic obstructive pulmonary disease.42e44 Many certified nursing aides are remarkably good at recognizing residents who have reduced their fluid intake and are at risk for dehydration.45,46 Certified nursing aides employ multiple strategies to improve the esthetic experience of drinking and promoting fluid intake.47 Despite these strategies, dehydration remains an important reason for transitions to hospital.48e51 This suggests the need for screening, tools for dehydration in the nursing home. Two check lists have been developed to determine dehydration risk. The Dehydration Risk Appraisal Checklist consists of 4 parts: (1) a section of significant health conditions; (2) a section on medications; (3) a section on intake behaviors; and (4) laboratory indicators.52 The “DEHYDRATIONS” screen is simpler3(Table 1). Urine color has also been suggested to be a rapid indicator of dehydration.53 None of these screening methods have, as yet, been adequately validated. The primary treatment of dehydration is to increase oral fluid intake.3,4 Often this is not possible in older persons, particularly those with dementia or other conditions such as dysphagia. A minimum fluid requirement for older persons is between 2 to 2.5 liters a day, with 20% coming from food. It is important, in this context, to think about different strategies to improve the fluid intake in elderly in Nursing Homes. For instance, flavored water (with mint leaves, lemon, or orange zest), may turn the liquids more attractive; the Table 1 Simple Screen for Dehydration Drugs (eg, diuretics) End of life High fever Yellow urine turns dark Dizziness (orthostasis) Reduced oral intake Axilla dry Tachycardia Incontinence (fear of) Oral problems/sippers Neurologic impairment (confusion) Sunken eyes
176
Editorial / JAMDA 16 (2015) 175e176
offering of liquid-rich fruits and vegetables (for instance, watermelon, cucumber, etc), could also contribute to prevent dehydration. However, when oral hydration is not possible in the nursing home subcutaneous infusion (hypodermoclysis) may be used.54,55 Between 1.5 to 3 liters a day can be given subcutaneously. This is the easiest way to give fluids in the nursing home and can play a major role in reducing hospital admissions. In most cases, when intravenous fluid is necessary, hospitalization will also be required. Overall subcutaneous infusions are greatly underutilized in nursing homes. Finally, it should be recognized that death from dehydration is not uncomfortable. In persons with end stage dementia or who are actively dying from other causes and are in hospital should have the choice given to them or their responsible party to limit fluid intake to whatever is comfortable for them.56e58 References 1. Bunn D, Jimoh F, Wilsher SH, Hooper L. Increasing fluid intake and reducing dehydration risk in older people living in long-term care: A systematic review. J Am Med Dir Assoc 2015;16:101e113. 2. Keller H, Beck AM, Namasivayam A. Improving food and fluid intake for older adults living in long-term care: A research agenda. J Am Med Dir Assoc 2015;16: 93e100. 3. Thomas DR, Cote TR, Lawhorne L, et al. Understanding clinical dehydration and its treatment. J Am Med Dir Assoc 2008;9:292e301. 4. Begum MN, Johnson CS. A review of the literature on dehydration in the institutionalized elderly. e-SPEN 2010;5:e47ee53. 5. Hooper L, Bunn D, Jimoh FO, Fairweather-Tait SJ. Water-loss dehydration and aging. Mech Ageing Dev 2014;136-137:50e58. 6. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: A call to action. J Am Med Dir Assoc 2013;14:392e397. 7. Garcia-Garcia FJ, Carcaillon L, Fernandez-Tresguerres J, et al. A new operational definition of frailty: The frailty trait scale. J Am Med Dir Assoc 2014;15:371. e7e371.e13. 8. Ng TP, Feng L, Nyunt MS, et al. Frailty in older persons: Multisystem risk factors and the Frailty Risk Index (FRI). J Am Med Dir Assoc 2014;15:635e642. 9. Shimada H, Makizako H, Doi T, et al. Combined prevalence of frailty and mild cognitive impairment in a population of elderly Japanese people. J Am Med Dir Assoc 2013;14:518e524. 10. Crecelius C. Dehydration: Myth and reality. J Am Med Dir Assoc 2008;9: 287e288. 11. Feinsod FM, Levenson SA, Rapp K, et al. Dehydration in frail, older residents in long-term care facilities. J Am Med Dir Assoc 2004;5:S35eS41. 12. Boockvar K, Signor D, Ramaswamy R, Hung W. Delirium during acute illness in nursing home residents. J Am Med Dir Assoc 2013;14:656e660. 13. Flaherty JH, Morley JE. Delirium in the nursing home. J Am Med Dir Assoc 2013; 14:632e634. 14. Rockwood K. Making delirium prevention acceptable in nursing homes. J Am Med Dir Assoc 2014;15:6e7. 15. Flaherty JH, Shay K, Weir C, et al. The development of a mental status vital sign for use across the spectrum of care. J Am Med Dir Assoc 2009;10: 379e380. 16. Jensdottir AB, Rantz M, Hjaltadottir I, et al. International comparison of quality indicators in United States, Icelandic and Canadian nursing facilities. Int Nurs Rev 2003;50:79e84. 17. Mentes JC, Culp K. Reducing hydration-linked events in nursing home residents. Clin Nurs Res 2003;12:210e225. 18. Wu SJ, Wang HH, Yeh SH, et al. Hydration status of nursing home residents in Taiwan: A cross-sectional study. J Adv Nurs 2011;67:583e590. 19. Palevsky PM, Ghargrath R, Greenberug A. Hypernatremia in hospitalize patients. Ann Intern Med 1996;124:197e203. 20. Rösler A, Lehmann F, Krause T, et al. Nutritional and hydration status in elderly subjects: Clinical rating versus bioimpedance analysis. Arch Gerontol Geriatr 2010;50:e81ee85. 21. Buffa R, Mereu RM, Putzu PF, et al. Bioelectrical impedance vector analysis detects low body cell mass and dehydration in patients with Alzheimer’s disease. J Nutr Health Aging 2010;14:823e827. 22. Kafri MW, Myint PK, Doherty D, et al. The diagnostic accuracy of multifrequency bioelectrical impedance analysis in diagnosing dehydration after stroke. Med Sci Monit 2013;19:548e570. 23. Kyle UG, Bosaeus I, De Lorenzo AD, et al. Bioelectrical impedance analysis, part I: Review of principles and methods. Clin Nutr 2004;23:1226e1243. 24. Olde Rikkert MG, Deurenberg P, Jansen RW, et al. Validation of multi-frequency bioelectrical impedance analysis in detecting changes in fluid balance of geriatric patients. J Am Geriatr Soc 1997;45:1345e1351. 25. Silver AJ, Morley JE, Strome LS, et al. Nutritional status in an academic nursing home. J Am Geriatr Soc 1988;36:487e491.
26. Davies I, O’Neill PA, McLean KA, et al. Age-associated alterations in thirst and arginine vasopressin in response to a water or sodium load. Age Ageing 1995; 24:151e159. 27. Silver AJ, Morley JE. Role of the opioid system in the hypodipsia associated with aging. J Am Geriatr Soc 1992;40:556e560. 28. Silver AJ, Morley JE, Ishimaru-Tseng TV, Morley PM. Angiotensin II and fluid ingestion in old rats. Neurobiol Aging 1993;14:519e522. 29. Rowe JW, Shock NW, Defronzo RA. The influence of age on the renal response to water deprivation in man. Nephron 1976;17:270e278. 30. Sands JM. Urinary concentration and dilution in the aging kidney. Semin Nephrol 2009;29:579e586. 31. Olde Rikkert MGM, Melis RJF, Claassen JAHR. Heat waves and dehydration in the elderly: Recognising the early warning signs can save lives. BMJ 2009;339: b2663. 32. Michel JP. Sarcopenia: There is a need for some steps forward. J Am Med Dir Assoc 2014;15:379e380. 33. Woo J, Leung J, Morley JE. Validating the SARC-F: A suitable community screening tool for sarcopenia? J Am Med Dir Assoc 2014;15:630e634. 34. Morley JE, Anker SD, von Haehling S. Prevalence, incidence, and clinical impact of sarcopenia: Facts, numbers, and epidemiologydupdate 2014. J Cachexia Sarcopenia Muscle 2014;5:253e259. 35. Mallery LH, Ransom T, Steeves B, et al. Evidence-informed guidelines for treating frail older adults with type 2 diabetes: From the Diabetes Care Program of Nova Scotia (DCPNS) and the Palliative and Therapeutic Harmonization (PATH) program. J Am Med Dir Assoc 2013;14:801e808. 36. Formiga F, Ferrer A, Padrós G, et al. Diabetes mellitus as a risk factor for functional and cognitive decline in very old people: The Octabaix study. J Am Med Dir Assoc 2014;15:924e928. 37. Sinclair A, Morley JE. How to manage diabetes mellitus in older persons in the 21st century: Applying these principles to long term diabetes care. J Am Med Dir Assoc 2013;14:777e780. 38. Sinclair A, Morley JE, Rodriguez-Mañas L, et al. Diabetes mellitus in older people: Position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes. J Am Med Dir Assoc 2012;13:497e502. 39. Morley JE. Inappropriate drug prescribing and polypharmacy are major cause of poor outcomes in long-term care. J Am Med Dir Assoc 2014;15:780e782. 40. Morley JE, Caplan G, Cesari M, et al. International survey of nursing home research priorities. J Am Med Dir Assoc 2014;15:309e312. 41. Fitzgerald SP, Bean NG. An analysis of the interactions between individual comorbidities and their treatmentsdimplications for guidelines and polypharmacy. J Am Med Dir Assoc 2010;11:475e484. 42. Kelaiditi E, Demougeot L, Lilamand M, et al. Nutritional status and the incidence of pneumonia in nursing home residents: Results from the INCUR study. J Am Med Dir Assoc 2014;15:588e592. 43. Morley JE. Chronic obstructive pulmonary disease: A disease of older persons. J Am Med Dir Assoc 2014;15:151e153. 44. Janssen DJ, Schols JM, Wouters EF, Spruit MA. One-year stability of care dependency in patients with advanced chronic organ failure. J Am Med Dir Assoc 2014;15:127e132. 45. Ullrich S, McCutcheon H. Nursing practice and oral fluid intake of older people with dementia. J Clin Nurs 2008;17:2910e2919. 46. Morley JE. Certified nursing assistants: A key to resident quality of life. J Am Med Dir Assoc 2014;15:610e612. 47. Godfrey H, Cloete J, Dymond E, Long A. An exploration of the hydration care of older people: A qualitative study. Int J Nurs Stud 2012;49:1200e1211. 48. Aaltonen M, Raitanen J, Forma L, et al. Burdensome transitions at the end of life among long-term care residents with dementia. J Am Med Dir Assoc 2014;15: 643e648. 49. Wong RY. Improving health care transitions for older adults through the lens of quality improvement. J Am Med Dir Assoc 2013;14:637e638. 50. Morley JE. Transitions. J Am Med Dir Assoc 2010;11:607e611. 51. Ouslander JG, Bonner A, Herndon L, Shutes J. The interventions to reduce acute care transfers (INTERACT) quality improvement program: An overview for medical directors and primary care clinicians in long term care. J Am Med Dir Assoc 2014;15:162e170. 52. Mentes JC, Wang J. Measuring risk for dehydration in nursing home residents: Evaluation of the dehydration risk appraisal checklist. Res Gerontol Nurs 2011; 4:148e156. 53. Wakefield B, Mentes J, Diggelmann L, Culp K. Monitoring hydration status in elderly veterans. West J Nurs Res 2002;14:132e142. 54. Cote TR. How to perform subcutaneous hydration. J Am Med Dir Assoc 2008;9: 291. 55. Dolamore MJ. The use of hypodermoclysis without hyaluronidase. J Am Med Dir Assoc 2009;10:75. author reply 75e76. 56. Volicer L, Stets K. Acceptability of an advance directive that limits food and liquids in advanced dementia. Am J Hosp Palliat Care; 2014 Oct 13 [Epub ahead of print]. 57. Unroe KT, Sachs GA, Hickman SE, et al. Hospice use among nursing home patients. J Am Med Dir Assoc 2013;14:254e259. 58. Morley JE. End-of-life care in the nursing home. J Am Med Dir Assoc 2011;12: 77e83.
JAMDA journal homepage: www.jamda.com
Editorial
Dehydration is Difficult to Detect and Prevent in Nursing Homes Sandra M. Lima Ribeiro PhD a, John E. Morley MB, BCh b, * a b
Gerontology Division, School of Arts, Sciences and Humanities, University of Sao Paulo, Sao Paulo, Brazil Divisions of Geriatric Medicine and Endocrinology, Saint Louis University School of Medicine, St. Louis, MO
“One should know that living beings are moist and warm .however old age is dry and cold”wAristotle The ancient Greeks, as attested to not only by Aristotle, but also by Homer, who compared old age with a dried olive branch, and Galen, who saw a major feature of aging as a loss of body water, perceived dehydration to be a central part of aging. The reality of this concept is further recognized by 2 recent articles in our Journal, examining the problems of maintaining fluid intake in residents in the nursing home.1,2 Dehydration is a failure to maintain adequate amounts of body water because of either poor fluid intake or pathologic loss of body fluids.3,4 Dehydration is associated with frailty, poor cognition, falls, delirium, disability, and mortality.5e15 Dehydration is a major cause of decreased attention and fluctuating mental status, the hallmarks of delirium, in the nursing home.12e15 In nursing homes, dehydration has been considered to be present in 0.8% to 1.4% of persons.16 A single nursing home study where dehydration was carefully looked for, suggested that the 6-month incidence of dehydration was as high as 1 in 3.17 In a nursing home in Taiwan, 45% of residents had a fluid intake below their estimated requirements.18 In hospitalized older persons, dehydration was present in 7.8%.19 The clinical diagnosis of dehydration is an underestimation compared with dehydration present as determined by bioelectrical impedance.20 Bioelectrical impedance suggests a high prevalence of dehydration in persons with end-stage Alzheimer’s disease.21 However, it needs to be noted that the accuracy of bioelectrical impedance at determining dehydration during rapid shifts of water between body compartments has been questioned. This questioning depends on the type of device (single or multifrequency) or on the type of analysis (predictive equations, vector analysis, or other).22e25 There are a number of reasons why older persons are at increased risk of water-loss dehydration. One of the most important is that as older persons become dehydrated, they fail to develop thirst at the same rate as younger persons.26 This appears, in part, to be due to alterations in angiotensin and in opioid neurotransmitters ability to modulate thirst with age.27,28 There is a decline in the kidney to retain fluid with aging, perhaps related to a decrease in vasopressin 2 receptors and aquaporins (water channels).29,30 Sarcopenia is the loss of The authors declare no conflicts of interest. * Address correspondence to John E. Morley, MB, BCh, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S Grand Blvd, M238, St. Louis, MO 63104. E-mail address: [email protected] (J.E. Morley). http://dx.doi.org/10.1016/j.jamda.2014.12.012 1525-8610/Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
muscle mass associated with aging.31e34 Muscle is the major water storage organ in the body.31 Thus, older persons have a lower fluid reserve than younger people. Other reasons for dehydration in older persons is the increased prevalence of diabetes mellitus that leads to fluid diuresis,35e38 the increase of polypharmacy and particularly diuretics to treat ankle edema,39e41 and excess sweating and hyperventilation because of infections or chronic obstructive pulmonary disease.42e44 Many certified nursing aides are remarkably good at recognizing residents who have reduced their fluid intake and are at risk for dehydration.45,46 Certified nursing aides employ multiple strategies to improve the esthetic experience of drinking and promoting fluid intake.47 Despite these strategies, dehydration remains an important reason for transitions to hospital.48e51 This suggests the need for screening, tools for dehydration in the nursing home. Two check lists have been developed to determine dehydration risk. The Dehydration Risk Appraisal Checklist consists of 4 parts: (1) a section of significant health conditions; (2) a section on medications; (3) a section on intake behaviors; and (4) laboratory indicators.52 The “DEHYDRATIONS” screen is simpler3(Table 1). Urine color has also been suggested to be a rapid indicator of dehydration.53 None of these screening methods have, as yet, been adequately validated. The primary treatment of dehydration is to increase oral fluid intake.3,4 Often this is not possible in older persons, particularly those with dementia or other conditions such as dysphagia. A minimum fluid requirement for older persons is between 2 to 2.5 liters a day, with 20% coming from food. It is important, in this context, to think about different strategies to improve the fluid intake in elderly in Nursing Homes. For instance, flavored water (with mint leaves, lemon, or orange zest), may turn the liquids more attractive; the Table 1 Simple Screen for Dehydration Drugs (eg, diuretics) End of life High fever Yellow urine turns dark Dizziness (orthostasis) Reduced oral intake Axilla dry Tachycardia Incontinence (fear of) Oral problems/sippers Neurologic impairment (confusion) Sunken eyes
176
Editorial / JAMDA 16 (2015) 175e176
offering of liquid-rich fruits and vegetables (for instance, watermelon, cucumber, etc), could also contribute to prevent dehydration. However, when oral hydration is not possible in the nursing home subcutaneous infusion (hypodermoclysis) may be used.54,55 Between 1.5 to 3 liters a day can be given subcutaneously. This is the easiest way to give fluids in the nursing home and can play a major role in reducing hospital admissions. In most cases, when intravenous fluid is necessary, hospitalization will also be required. Overall subcutaneous infusions are greatly underutilized in nursing homes. Finally, it should be recognized that death from dehydration is not uncomfortable. In persons with end stage dementia or who are actively dying from other causes and are in hospital should have the choice given to them or their responsible party to limit fluid intake to whatever is comfortable for them.56e58 References 1. Bunn D, Jimoh F, Wilsher SH, Hooper L. Increasing fluid intake and reducing dehydration risk in older people living in long-term care: A systematic review. J Am Med Dir Assoc 2015;16:101e113. 2. Keller H, Beck AM, Namasivayam A. Improving food and fluid intake for older adults living in long-term care: A research agenda. J Am Med Dir Assoc 2015;16: 93e100. 3. Thomas DR, Cote TR, Lawhorne L, et al. Understanding clinical dehydration and its treatment. J Am Med Dir Assoc 2008;9:292e301. 4. Begum MN, Johnson CS. A review of the literature on dehydration in the institutionalized elderly. e-SPEN 2010;5:e47ee53. 5. Hooper L, Bunn D, Jimoh FO, Fairweather-Tait SJ. Water-loss dehydration and aging. Mech Ageing Dev 2014;136-137:50e58. 6. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: A call to action. J Am Med Dir Assoc 2013;14:392e397. 7. Garcia-Garcia FJ, Carcaillon L, Fernandez-Tresguerres J, et al. A new operational definition of frailty: The frailty trait scale. J Am Med Dir Assoc 2014;15:371. e7e371.e13. 8. Ng TP, Feng L, Nyunt MS, et al. Frailty in older persons: Multisystem risk factors and the Frailty Risk Index (FRI). J Am Med Dir Assoc 2014;15:635e642. 9. Shimada H, Makizako H, Doi T, et al. Combined prevalence of frailty and mild cognitive impairment in a population of elderly Japanese people. J Am Med Dir Assoc 2013;14:518e524. 10. Crecelius C. Dehydration: Myth and reality. J Am Med Dir Assoc 2008;9: 287e288. 11. Feinsod FM, Levenson SA, Rapp K, et al. Dehydration in frail, older residents in long-term care facilities. J Am Med Dir Assoc 2004;5:S35eS41. 12. Boockvar K, Signor D, Ramaswamy R, Hung W. Delirium during acute illness in nursing home residents. J Am Med Dir Assoc 2013;14:656e660. 13. Flaherty JH, Morley JE. Delirium in the nursing home. J Am Med Dir Assoc 2013; 14:632e634. 14. Rockwood K. Making delirium prevention acceptable in nursing homes. J Am Med Dir Assoc 2014;15:6e7. 15. Flaherty JH, Shay K, Weir C, et al. The development of a mental status vital sign for use across the spectrum of care. J Am Med Dir Assoc 2009;10: 379e380. 16. Jensdottir AB, Rantz M, Hjaltadottir I, et al. International comparison of quality indicators in United States, Icelandic and Canadian nursing facilities. Int Nurs Rev 2003;50:79e84. 17. Mentes JC, Culp K. Reducing hydration-linked events in nursing home residents. Clin Nurs Res 2003;12:210e225. 18. Wu SJ, Wang HH, Yeh SH, et al. Hydration status of nursing home residents in Taiwan: A cross-sectional study. J Adv Nurs 2011;67:583e590. 19. Palevsky PM, Ghargrath R, Greenberug A. Hypernatremia in hospitalize patients. Ann Intern Med 1996;124:197e203. 20. Rösler A, Lehmann F, Krause T, et al. Nutritional and hydration status in elderly subjects: Clinical rating versus bioimpedance analysis. Arch Gerontol Geriatr 2010;50:e81ee85. 21. Buffa R, Mereu RM, Putzu PF, et al. Bioelectrical impedance vector analysis detects low body cell mass and dehydration in patients with Alzheimer’s disease. J Nutr Health Aging 2010;14:823e827. 22. Kafri MW, Myint PK, Doherty D, et al. The diagnostic accuracy of multifrequency bioelectrical impedance analysis in diagnosing dehydration after stroke. Med Sci Monit 2013;19:548e570. 23. Kyle UG, Bosaeus I, De Lorenzo AD, et al. Bioelectrical impedance analysis, part I: Review of principles and methods. Clin Nutr 2004;23:1226e1243. 24. Olde Rikkert MG, Deurenberg P, Jansen RW, et al. Validation of multi-frequency bioelectrical impedance analysis in detecting changes in fluid balance of geriatric patients. J Am Geriatr Soc 1997;45:1345e1351. 25. Silver AJ, Morley JE, Strome LS, et al. Nutritional status in an academic nursing home. J Am Geriatr Soc 1988;36:487e491.
26. Davies I, O’Neill PA, McLean KA, et al. Age-associated alterations in thirst and arginine vasopressin in response to a water or sodium load. Age Ageing 1995; 24:151e159. 27. Silver AJ, Morley JE. Role of the opioid system in the hypodipsia associated with aging. J Am Geriatr Soc 1992;40:556e560. 28. Silver AJ, Morley JE, Ishimaru-Tseng TV, Morley PM. Angiotensin II and fluid ingestion in old rats. Neurobiol Aging 1993;14:519e522. 29. Rowe JW, Shock NW, Defronzo RA. The influence of age on the renal response to water deprivation in man. Nephron 1976;17:270e278. 30. Sands JM. Urinary concentration and dilution in the aging kidney. Semin Nephrol 2009;29:579e586. 31. Olde Rikkert MGM, Melis RJF, Claassen JAHR. Heat waves and dehydration in the elderly: Recognising the early warning signs can save lives. BMJ 2009;339: b2663. 32. Michel JP. Sarcopenia: There is a need for some steps forward. J Am Med Dir Assoc 2014;15:379e380. 33. Woo J, Leung J, Morley JE. Validating the SARC-F: A suitable community screening tool for sarcopenia? J Am Med Dir Assoc 2014;15:630e634. 34. Morley JE, Anker SD, von Haehling S. Prevalence, incidence, and clinical impact of sarcopenia: Facts, numbers, and epidemiologydupdate 2014. J Cachexia Sarcopenia Muscle 2014;5:253e259. 35. Mallery LH, Ransom T, Steeves B, et al. Evidence-informed guidelines for treating frail older adults with type 2 diabetes: From the Diabetes Care Program of Nova Scotia (DCPNS) and the Palliative and Therapeutic Harmonization (PATH) program. J Am Med Dir Assoc 2013;14:801e808. 36. Formiga F, Ferrer A, Padrós G, et al. Diabetes mellitus as a risk factor for functional and cognitive decline in very old people: The Octabaix study. J Am Med Dir Assoc 2014;15:924e928. 37. Sinclair A, Morley JE. How to manage diabetes mellitus in older persons in the 21st century: Applying these principles to long term diabetes care. J Am Med Dir Assoc 2013;14:777e780. 38. Sinclair A, Morley JE, Rodriguez-Mañas L, et al. Diabetes mellitus in older people: Position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes. J Am Med Dir Assoc 2012;13:497e502. 39. Morley JE. Inappropriate drug prescribing and polypharmacy are major cause of poor outcomes in long-term care. J Am Med Dir Assoc 2014;15:780e782. 40. Morley JE, Caplan G, Cesari M, et al. International survey of nursing home research priorities. J Am Med Dir Assoc 2014;15:309e312. 41. Fitzgerald SP, Bean NG. An analysis of the interactions between individual comorbidities and their treatmentsdimplications for guidelines and polypharmacy. J Am Med Dir Assoc 2010;11:475e484. 42. Kelaiditi E, Demougeot L, Lilamand M, et al. Nutritional status and the incidence of pneumonia in nursing home residents: Results from the INCUR study. J Am Med Dir Assoc 2014;15:588e592. 43. Morley JE. Chronic obstructive pulmonary disease: A disease of older persons. J Am Med Dir Assoc 2014;15:151e153. 44. Janssen DJ, Schols JM, Wouters EF, Spruit MA. One-year stability of care dependency in patients with advanced chronic organ failure. J Am Med Dir Assoc 2014;15:127e132. 45. Ullrich S, McCutcheon H. Nursing practice and oral fluid intake of older people with dementia. J Clin Nurs 2008;17:2910e2919. 46. Morley JE. Certified nursing assistants: A key to resident quality of life. J Am Med Dir Assoc 2014;15:610e612. 47. Godfrey H, Cloete J, Dymond E, Long A. An exploration of the hydration care of older people: A qualitative study. Int J Nurs Stud 2012;49:1200e1211. 48. Aaltonen M, Raitanen J, Forma L, et al. Burdensome transitions at the end of life among long-term care residents with dementia. J Am Med Dir Assoc 2014;15: 643e648. 49. Wong RY. Improving health care transitions for older adults through the lens of quality improvement. J Am Med Dir Assoc 2013;14:637e638. 50. Morley JE. Transitions. J Am Med Dir Assoc 2010;11:607e611. 51. Ouslander JG, Bonner A, Herndon L, Shutes J. The interventions to reduce acute care transfers (INTERACT) quality improvement program: An overview for medical directors and primary care clinicians in long term care. J Am Med Dir Assoc 2014;15:162e170. 52. Mentes JC, Wang J. Measuring risk for dehydration in nursing home residents: Evaluation of the dehydration risk appraisal checklist. Res Gerontol Nurs 2011; 4:148e156. 53. Wakefield B, Mentes J, Diggelmann L, Culp K. Monitoring hydration status in elderly veterans. West J Nurs Res 2002;14:132e142. 54. Cote TR. How to perform subcutaneous hydration. J Am Med Dir Assoc 2008;9: 291. 55. Dolamore MJ. The use of hypodermoclysis without hyaluronidase. J Am Med Dir Assoc 2009;10:75. author reply 75e76. 56. Volicer L, Stets K. Acceptability of an advance directive that limits food and liquids in advanced dementia. Am J Hosp Palliat Care; 2014 Oct 13 [Epub ahead of print]. 57. Unroe KT, Sachs GA, Hickman SE, et al. Hospice use among nursing home patients. J Am Med Dir Assoc 2013;14:254e259. 58. Morley JE. End-of-life care in the nursing home. J Am Med Dir Assoc 2011;12: 77e83.
