Comparison of Four Standards for Determining Adequate Water Intake of Nursing Home Residents

Adequate hydration for nursing home residents is problematic. The purpose of this study was to compare four standards used to determine a recommended water intake among nursing home residents. Inconsistencies in the amount of water intake recommended based on the standards compared were identified. The standard based on height and weight provides the most individualized recommendation. An individualized recommendation would facilitate goal setting for the care plan of each older person and assist in the prevention of dehydration. It is essential that a cost-effective and clinically feasible approach to determine adequate water intake be determined for this population to prevent the adverse outcomes associated with dehydration. Keywords: dehydration; hydration; water intake standards; elderly; long-term care Dehydration is a sentinel health event among older persons in nursing homes portending serious secondary and life-threatening problems and is a prime target for litigation (Weinberg & Levine, 2005). Inadequate water intake is often preventable when care is adequate or should signal nurses to question why it is inadequate. Although various conditions or situations contribute to dehydration among older nursing home residents, the problem is ultimately related to increased water loss or inadequate water intake. Nursing home residents have been described as having a chronic mild state of dehydration (Bennett, Thomas, & Riegel, 2004), with approximately one-third reported to be dehydrated (Mentes, 2006). Common age-associated changes of lowered body water content, decreased thirst sensation, and decline in kidney function result in lowered reserve and ability to compensate for a loss of body water for older residents. Serious conditions documented as a result of dehydration include urinary tract infections, respiratory infections, urinary incontinence, constipation, falls, and acute confusion (Bennett et al., 2004; Mentes & Culp, 2003; Mentes, Culp, Rantz, & Maas, 1999). The simplest way for older persons to improve hydration is to consume adequate fluids. However, from a clinical perspective, increasing the water intake of nursing home residents is anything but simple. Mentes, Chang, and Morris (2006) report that certified nursing assistants, who have responsibility for assisting nursing home residents with eating and hydration, identify this task to be intensive work. Several investigators have tested interventions to increase the water intake of this population. However, existence of multiple standards for adequate water intake of older nursing home residents indicates an unresolved question for both researchers and clinicians. Two studies have reported the comparison of several standards of water intake for nursing home residents. Chidester and Spangler (1997) compared three standards for determining recommendations for water intake with the actual intake of 40 nursing home residents. Holben, Hassell, Williams, and Helle (1999) replicated aspects of the Chidester and Spangler study, comparing the standards with the intake of 121 nursing home residents. The three common standards compared in both studies were (a) Standard 1: 30 ml fluid per kilogram actual body weight (ABW); (b) Standard 2: 1 ml fluid per kilocalorie energy consumed; and (c) Standard 3: 100 ml fluid per kilogram for first 10 kg ABW, 50 ml fluid per kilogram for next 10 kg ABW, and 15 ml fluid per kilogram for remaining kilogram ABW. Background information for each of these standards is provided in Table 1. Chidester and Spangler (1997) and Holben et al. (1999) differ in the standard that is recommended. Standard 3 is recommended by Chidester and Spangler because the calculation corrects for those who are extremely underweight and overweight and supplies a minimum of 1,500 ml of fluid for anyone weighting more than 20 kg. These authors comment that Standard 1 provides an unrealistically low fluid intake with less than a minimum of 1,500 ml for low-weight individuals. …