Clinical Presentation of Hypernatremia in Elderly Patients: A Case Control Study

Chassagne, Philippe; Laurent, Dimitri; Capet, C.; Ménard, Jean François; Bercoff, É.

doi:10.1111/j.1532-5415.2006.00807.x

Cited by 63 publications

(37 citation statements)

References 19 publications

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“…Vertical error lines represent sensitivity 95% CI, horizontal error lines represent specificity 95% CI. assess hydration, 13,15 altering posture may be impractical in a clinical setting, particularly in bed-ridden patients. Therefore, a sitting blood pressure assessment may have practical value for the clinician.…”

Section: Discussionmentioning

confidence: 99%

“…9e12 However, blood sample collection is invasive and laboratory analysis is time-consuming, often delaying the course of treatment by hours. To aid an initial diagnosis of dehydration before requesting blood biochemistry confirmation, clinicians may use a variety of simple screening measures, albeit in a nonsystematic way, that may include presenting signs and symptoms of dehydration, 11,13,14 patient history, 13 orthostatic blood pressure change, 15 and/or urinary parameters. 16 Nevertheless, these screening methods are often characterized by poor diagnostic performance.…”

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confidence: 99%

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Is This Elderly Patient Dehydrated? Diagnostic Accuracy of Hydration Assessment Using Physical Signs, Urine, and Saliva Markers

Fortes

Owen

Raymond-Barker

et al. 2015

Journal of the American Medical Directors Association

129

102

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Objectives: Dehydration in older adults contributes to increased morbidity and mortality during hospitalization. As such, early diagnosis of dehydration may improve patient outcome and reduce the burden on healthcare. This prospective study investigated the diagnostic accuracy of routinely used physical signs, and non-invasive markers of hydration in urine and saliva. Design: Prospective diagnostic accuracy study. Setting: Hospital acute medical care unit and emergency department. Participants: One hundred and thirty older adults (59 males, 71 females, mean (SD) age = 78 (9) y). Measurements: Participants with any primary diagnosis underwent a hydration assessment within 30min of admittance to hospital. Hydration assessment comprised seven physical signs of dehydration (tachycardia (>100bpm), low systolic blood pressure (<100mmHg), dry mucous membrane, dry axilla, poor skin turgor, sunken eyes, and long capillary refill time (>2s)), urine color, urine specific gravity (USG), saliva flow rate (SFR) and saliva osmolality. Plasma osmolality (Posm) and the blood urea nitrogen to creatinine ratio (BUN:Cr) were assessed as reference standards of hydration, with 21% of participants classified with water-loss dehydration (Posm >295mOsm/kg), 19% classified with water-and-solute-loss dehydration (BUN:Cr >20) and 60% classified as euhydrated. Results: All physical signs showed poor sensitivity (0-44%) for detecting either form of dehydration, with only low systolic blood pressure demonstrating potential utility for aiding the diagnosis of water-and-solute-loss dehydration (diagnostic OR = 14.7). Neither urine color, USG, nor SFR could discriminate hydration status (area under the receiver operating characteristic curve, AUCROC = 0.49-0.57, P>0.05). In contrast, saliva osmolality demonstrated moderate diagnostic accuracy (AUCROC = 0.76, P<0.001) to distinguish both dehydration types (70% sensitivity, 68% specificity, OR =5.0 (95%CI 1.7-15.1) for water-loss dehydration, and 78% sensitivity, 72% specificity, OR =8.9 (95%CI 2.5-30.7) for water-and-solute-loss dehydration). Conclusions: With the exception of low systolic blood pressure, which could aid in the specific diagnosis of water-and-solute-loss dehydration, physical signs and urine markers show little utility to determine if an elderly patient is dehydrated. Saliva osmolality demonstrated superior diagnostic accuracy compared with physical signs and urine markers, and may have utility for the assessment of both water-loss and water-andsolute-loss dehydration in older individuals. It is particularly noteworthy that saliva osmolality was able to detect water-and-solute-loss dehydration, for which a measurement of plasma osmolality would have no diagnostic utility. Thankyou for allowing us to resubmit the above manuscript to your journal. We have responded to the reviewers comments (see below), with changes in the manuscript highlighted in red text. We hope you feel that these changes have improved the manuscript.Please don't hesitate to contact me if you require...

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Is This Elderly Patient Dehydrated? Diagnostic Accuracy of Hydration Assessment Using Physical Signs, Urine, and Saliva Markers

Fortes

Owen

Raymond-Barker

et al. 2015

Journal of the American Medical Directors Association

129

102

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“…Individuals at risk of insufficient drinking often have an altered mental status (critical illness, sedation, neurological impairment) or they are intubated patients, infants [98] or geriatric patients [99]. …”

Section: Part 2: Hypernatraemiamentioning

confidence: 99%

Clinical review: Practical approach to hyponatraemia and hypernatraemia in critically ill patients

Overgaard-Steensen

Ring

2012

Crit Care

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Disturbances in sodium concentration are common in the critically ill patient and associated with increased mortality. The key principle in treatment and prevention is that plasma [Na+] (P-[Na+]) is determined by external water and cation balances. P-[Na+] determines plasma tonicity. An important exception is hyperglycaemia, where P-[Na+] may be reduced despite plasma hypertonicity. The patient is first treated to secure airway, breathing and circulation to diminish secondary organ damage. Symptoms are critical when handling a patient with hyponatraemia. Severe symptoms are treated with 2 ml/kg 3% NaCl bolus infusions irrespective of the supposed duration of hyponatraemia. The goal is to reduce cerebral symptoms. The bolus therapy ensures an immediate and controllable rise in P-[Na+]. A maximum of three boluses are given (increases P-[Na+] about 6 mmol/l). In all patients with hyponatraemia, correction above 10 mmol/l/day must be avoided to reduce the risk of osmotic demyelination. Practical measures for handling a rapid rise in P-[Na+] are discussed. The risk of overcorrection is associated with the mechanisms that cause hyponatraemia. Traditional classifications according to volume status are notoriously difficult to handle in clinical practice. Moreover, multiple combined mechanisms are common. More than one mechanism must therefore be considered for safe and lasting correction. Hypernatraemia is less common than hyponatraemia, but implies that the patient is more ill and has a worse prognosis. A practical approach includes treatment of the underlying diseases and restoration of the distorted water and salt balances. Multiple combined mechanisms are common and must be searched for. Importantly, hypernatraemia is not only a matter of water deficit, and treatment of the critically ill patient with an accumulated fluid balance of 20 litres and corresponding weight gain should not comprise more water, but measures to invoke a negative cation balance. Reduction of hypernatraemia/hypertonicity is critical, but should not exceed 12 mmol/l/day in order to reduce the risk of rebounding brain oedema.

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“…subjectively and without baselines. Skin turgor may be affected by age-related alterations in elastin levels and assessment is known to be unreliable between examiners in the elderly population 24. Mucous membrane moistness in the mouth is affected by the same wide variation in individual saliva flow which affect ability to spit20 21(see below).…”

Section: Discussionmentioning

confidence: 99%

Sensitivity and specificity of clinical signs for assessment of dehydration in endurance athletes

et al. 2008

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Clinical Presentation of Hypernatremia in Elderly Patients: A Case Control Study

Abstract: Most of the classical signs of dehydration are irregularly present in patients with hypernatremia. Caregivers should carefully screen any variations in consciousness, because they may reveal severe hypernatremia.

Cited by 63 publications

References 19 publications

Is This Elderly Patient Dehydrated? Diagnostic Accuracy of Hydration Assessment Using Physical Signs, Urine, and Saliva Markers

Is This Elderly Patient Dehydrated? Diagnostic Accuracy of Hydration Assessment Using Physical Signs, Urine, and Saliva Markers

Clinical review: Practical approach to hyponatraemia and hypernatraemia in critically ill patients

Sensitivity and specificity of clinical signs for assessment of dehydration in endurance athletes

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