· web viewto determine whether the position adopted by the feeding assistant influences food...

Systematic review: reducing dehydration risk Resubmission 1, 26/10/2014 Submission 27/07/2014

Web Table 1 : Characteristics of included studies, full details of intervention studies

Author Ethical review

Study design, aims and methods Participants: selection & baseline characteristics Intervention, Control and Duration

Description of outcome measure & definition of low fluid intake or dehydration used by authors

*Allen,1,2

2011UK

Yes Design:RCT, unblinded.Web-based random numbers table used for allocation following consentAim(s) examined in this review:To analyse the influence of serving method on consumption of ONS drinks in older adults.Recruitment methods: potential participants identified by facility staffSetting:Nursing home. Size N/R

Baseline characteristics, Groups 1 (n=8) & 2 (n=16) combined:Age, years, mean (SD): 86.3 (8.9), range: 66-97MMSE, mean (SD), range: 11.3 (9.7), 0-30 Gender, functional ability: not reportedInclusion criteria: Consultee consent required due to cognitive impairment >65 yearsExclusion criteria:Unstable DMInvestigations for DMDysphagia requiring thickened fluidsLactose intoleranceCoeliac diseaseAllergy to ONSDeliriumFluid restriction <1l/day

Group 1:Straw inserted into ONS bottle.Group 2: ONS decanted into a glass/beaker.Duration:x3 per day, alternate days one week.

Outcome measure(s):Proportion of ONS consumed, per number of drinks served.Method of assessment:Amount of ONS consumed estimated as a proportion of amount served (0.1, 0.25, 0.5, 0.75, 1.0). Method of estimation not described.Outcome assessors: research staffDefinition of low fluid intake: N/R

*Allison,3 2005US

N/R Design:Before-afterPretest-posttest, non-randomised, uncontrolled, unblinded Aim(s) examined in this review:To assess effectiveness of nursing practices to increase hydration in residents with TBR >550ohms.Recruitment method, main study:1225 residents selected by reviewing medical records Recruitment method, sub-study included in this review: N/RSetting:26 long-term care facilities (17 urban, 9 rural), Texas, US. Size of facilities N/R

Baseline characteristics, main study, n=1225: Age, years, mean: 76 (SD N/R), range: 20-104; 89.4% ≥60 years.Males: 471 (38.4%)Body weight, kg, mean: 71.89 (SD N/R)Cognitive ability: N/RFunctional ability: N/RBaseline characteristics, sub-study included in this review: n=281 recruited to study and n=198 completed with outcomes reported. Characteristics of sub-study group N/R separately from the main studyInclusion criteria, main study:Residents having a profile of non-invasive measures for clinical management purposes.Inclusion criteria, sub-study: TBR readings >550ohmsConsent.

Senior facility staff evaluated participants and intervened with the appropriate care (not described) if required, to improve hydrationDuration: 3-4 months

Outcome measure(s):Change in BIA reading of TBR.Method of assessment:Quantum II Bioimpedence Anlayzer. Software: Cyprus Body Composition Software system - RJL SystemsEquation: TBW/(height2/TBR) x height/ResistanceOutcome assessors: N/RDefinition of low TBR: Hypovolemic risk and risk of dehydration defined as TBR >550ohms (average TBR: 504.81 ohms).

*Cleary,4

2008.Canada

N/R Design:Before-afterPretest-posttest, non-randomised, uncontrolled, unblindedAim(s) examined in this review:To evaluate effects of routine mealtime seating plan on fluid intake in residents

Baseline characteristics, n=4:(n=1 RIP during the study; study reported on n=3)Age, years, mean: 92.7 (SD N/R); range, 88-97Sex: N/RDiet level: pureed diet & nectar-thick fluids, n=2; regular texture & thin liquids, n=1.

Regular seating plan instituted for this study at lunchtimes.Duration: N/R, but 12 meals observed over non-consecutive days

Outcome measure(s):Change in percentage of fluids consumed at lunch as a proportion of amount served (amount served N/R)Outcome assessors: N/RMethod of assessment: N/R

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with dementia and at risk of nutritional decline.Recruitment method: N/R Setting:Long-term care facility. Size N/R

MMSE, mean: 11.0 (SD N/R), range: 5-14Functional ability: N/RInclusion criteria:Diagnosis of dementiaAdequate vision and hearing for normal conversationResident for ≥3 monthsRisk of nutritional declineMeals taken in the dining roomAble to self-feed >25% of meal for at least 2 days per weekExclusion criteria:Medications to stimulate dietDepression

Definition of low fluid intake: N/R

Dunne,5

2004US

N/R Design:Before-afterPretest-posttest, non-randomised, uncontrolled, unblindedAim(s) examined in this review:To investigate whether using high and low contrast tableware increased fluid intake in males with advanced ADRecruitment method: N/RSetting:Long-term care unit. Size N/R

Baseline characteristics, study 1, n=9:Age, years, mean: 82.7 (SD N/R), range: 72-89MMSE, mean: 2.9 (SD N/R), range 0-8Functional ability: N/RVisual abilities (acuity, colour discrimination, contrast sensitivity): assessment attempted, but no participant was able to complete the testing.Baseline characteristics, study 2, n=9 (included 5 participants from Study 1; n=3 RIP during the study).Participant characteristics N/R fully, but the 4 new men were described as being matched for age, education level and MMSE with the 4 participants they replaced.Age, mean: 83.1 (range and SD N/R)MMSE, mean: 3.2 (range and SD N/R)Inclusion criteria, both studies: Advanced ADAble to eat independently Exclusion criteria, both studies: Serious medical conditionsUncontrolled seizuresHypertensionDiabetes mellitusNeurological disease.

Study 1: white tableware (control), high-contrast red tableware, white Duration: 30 days (10 days each)Study 2 (1 year later): white tableware, high-contrast blue (n=9), white, low-contrast red (n=7), white, low-contrast blue (n=6), whiteDuration: 70 days (10 days each)

Outcome measure(s):Change in mean percentage of fluid intake.Method of assessment:Food and fluid intake recorded every day for each participant at lunchAmount consumed expressed as a percentage of amount served. Amount served was weighed in ounces.Outcome assessors: N/RDefinition of low fluid intake: N/R

Fries,6

1997US

N/R Design:Before-afterPretest-posttest, uncontrolled, unblindedAim(s) examined in this review:To evaluate effect of implementing RAI-MDS on prevalence of dehydration at baseline and numbers

Baseline characteristics, pre/post intervention:Pre-intervention (1990): n=2128Post intervention (1993): n=2088 (new cohort).Baseline characteristics were combined for both the pre/post intervention groups and reported as raw frequency and weighted percentages of the total population they represent (n=121,337):Age, n (%):

Implementation of RAI-MDS, commenced in USA Autumn 1990.

Outcome measure(s):Change in baseline dehydration prevalence.Change in number of residents acquiring dehydration or improving during 6 months follow-up.Method of assessment & definition

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of participants declining or improving during 6-month follow-up periodPre-RAI, recruitment method, nursing homes:Purposive sampling to select facilities representing geographical location, size (>25 beds), urban/rural setting; high/low staffing levels; Medicaid reimbursement level; re-imbursement methodology (case mix/non-case mix).Post-RAI, recruitment method, nursing homes:Same nursing homes, but 14 lost to follow-up (10 declined, 3 closed, 1 ‘ineligible’, reason N/R).Pre-RAI, recruitment method, residents:8-16 residents (dependant on size of facility) stratified by length of stay (25% 30-60 days, 75% >60 days) selected from resident census at each facility on the first day of data collection by research staff.Post-RAI, recruitment method, residents:8-16 residents randomly selected from resident census at each facility on the first day of data collection by research staff (not stratified by length of stay and details of randomisation N/R).Setting:268 nursing homes in 10 US states.

<65 years n=308 (6.9)65-74 years n=513 (11.5)75-84 years n=1384 (33.2)>85 years n=2029 (48.4)Males, n (%): 1026 (23.3)CPS, n (%):Intact:1296 (30.9)Moderate: 1507 (34.6)Severe: 1407 (34.5)ADL, n (%):Independent: 770 (19.0)Limited: 1279 (29.6)Dependent: 2150 (51.4)

of dehydration:Dehydration present/absent as defined by the RAI-MDS, ≥2 criteria present from the following:Fluid intake <1.5l/dayClinical signs of dehydrationFluid loss > fluid intake.Methods used to assess these N/R.Outcome assessors: research staff

Holzapfel,7

1997US

N/R Design:RCTc, unblindedDetails of randomisation N/RAim(s) examined in this review:To determine whether the position adopted by the feeding assistant influences food and fluid intake in residents requiring complete feeding assistance.Recruitment method:

Baseline characteristics, reported for the 3 groups combined, n=39:Age, years, mean (range): 75 (40-99). 95% aged ≥60 years.Males: 3 (8%).Dementia diagnosis: 22 (56.4%).Functional ability: N/RInclusion criteria: Complete feeding assistance required for each mealExclusion criteria: Enteral feeding.

Intervention groups: Feeding assistants sat for 2 weeks, then stood for 2 weeks, then crossed over. Control: Feeding assistants chose positions (positions chosen N/R)Duration: Lunch, Monday – Friday, 4 weeks

Outcome measure(s):Differences in mean fluid intake between the three groups on days 1,5,10,15,20 of the study. Results presented as t statistic and p value.Method of assessment:Food and fluid consumed, at mid-day meal only, was recorded by the feeder using four pre-determined categories of percentages (0-25%, 26-50%, 51-

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N/R, but participants randomly assigned to one of three groups.Setting:240-bed nursing home unit in a 1000-bed medical centre.

Feeding assistance provided by non-designated feeders. 75%, 76-100%). Not known if this was measured or estimated.Fluid defined as being able to be consumed through a straw.Outcome assessors: facility staff delivering intervention.Definition of low fluid intake: N/R

*Kenkman,8

2010UK

Yes Design:Cluster CCT, non-randomised, unblindedAim(s) examined in this review:To assess the health, well-being & nutritional status of older people living in residential care.Recruitment method, homes:3 residential homes already selected for development by Norfolk County Council (NCC). These were matched by resident population size with 3 other homes owned by NCC.Recruitment method, resident:n=213 approachedn=105 case note review (63 at year 1)n=87 interviews (56 completed 1 year follow-up interviews, and this sub-study reported here)n=42 RIP/moved away/declined

Baseline characteristics for intervention group completing 1 year follow-up, n=30 (sub-study):MMSE, mean (SD): 19 (5.6)Residents attempting chair-stands: 6 (20%)Age & sex N/R for this group separately, but characteristics from main study (n=57):Age, mean (SD): 86.1 (6.7).Males: 19 (33%)Baseline characteristics for control group, completing 1 year follow-up, n=26 (sub-study):MMSE, mean (SD): 17 (6.2). p=0.21†

Residents attempting chair-stands: 4 (15.4%). p=0.65†

Age & sex N/R for this group separately, but characteristics from main study (n=48): Age, mean (SD): 87.7 (6.8), p=0.23Males: 12 (25%), p=0.35Inclusion criteria, residents:ConsentExclusion criteria, residents:Short stay

Intervention: Improved comfort for mealtimes, including restaurant atmosphere & extended mealtimes, increased choice of foods, Improved social experience, visitors encouraged to eat at care home, increased encouragement to eat, increased availability of drinks and snacks to residents and visitorsControl: ‘Usual care’ (not described).Duration: 12 months

Outcome measure(s) ‡:Change in number of residents with dehydration.Method of assessment & definition of dehydration:Presence of either:Dry, furrowed tongueDry mucous membraneSunken eyesMethods used to assess these N/ROutcome assessors: research staff

Lin,9

2013Taiwan

Yes Design:Cluster CCT, non-randomised, unblinded.Aim(s) examined in this review:Pilot study to assess whether increased fluid intake reduces asymptomatic bacteria in incontinent nursing home residents over 6 weeks.Recruitment method, nursing homes:Voluntary group assignment (homes chose whether they were intervention or control)Recruitment method, residents:n=86 eligible (identified by nursing

Baseline characteristics, intervention group, n=44:Age, years, mean (SD): 75.5 (12.7)Males: 14 (31.8%) SPMSQ, mean (SD): 5.4 (3.6)Barthel Index, mean (SD): 28.6 (24.4)MNA, mean (SD): 19.3 (3.0)Occasional incontinence: 9 (20.5%)Frequent incontinence: 13 (29.5%)History of UTI: 19 (43.2%)Baseline characteristics, control group, n=30:Age, years, mean (SD): 74.7 (10.8), p=0.769†

Males: 15 (50%), p=0.116†

SPMSQ, mean (SD): 6.6 (3.2), p=0.13†

Barthel Index, mean (SD): 32.2 (24.8), p=0.545†

MNA, mean (SD): 18.4 (4.4), p=0.332†

Intervention group: advice to increase fluid intake to >1500mls/day (description of advice provide N/R), unrestricted choice of drinks.Control group: unrestricted drinks, residents could choose type and amount.Duration: 6 weeks

Outcome measure(s) ‡:Change in mean fluid intake. Methods of assessment:Fluid input/output charts completed by facility staff, but methods of measuring fluids N/R.Outcome assessors: facility staffDefinition of low fluid intake: Adequate fluid intake not defined, but assumed that insufficient fluid intake ≤1500mls/day, as the aim was to increase fluids to ≥1500mls/day.

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home staff)n=6 withdrew (2 hospitalised, 4 RIP)n=74 completedSetting:6 nursing homes (30-120 beds).

Occasional incontinence: 8 (26.7%) p=0.53Frequent incontinence: 8 (26.7%), p=0.79†

History of UTI: 12 (40%), p=0.785†

Inclusion criteria:Urinary incontinenceExclusion criteria:Indwelling urinary catheterSevere mental impairmentCurrent urological diseaseCurrent UTICurrent antibioticsInability to produce 2 urine specimens

*McCormick10,11

2006Ireland

Stated as not required

Design:RCTc, un-blinded Aim(s) examined in this review:In residents with dysphagia, fluid intake was compared between residents receiving drinks, thickened at the bedside by staff compared with commercially pre-prepared thickened drinks.Recruitment method: N/RSetting:Long-term care unit within a 321-bed faciltity which included acute and rehabilitation units.

Baseline characteristics, n=11:Age, years, mean (range): 76 (51-109)Males: 3 (27%)MMSE administered, results N/RBarthel index, mean: 0.4 (SD N/R)Inclusion criteria: Dysphagia, at risk of aspiration

Weeks 1-6: Group A received commercially-prepared pre-thickened drinks, Group B received drinks thickened at bedsideWeeks 7-12: Group A: drinks thickened at bedside, Group B: commercially-prepared pre-thickened drinksDuration: 12 weeks

Outcome measure(s) ‡:Difference in amount of thickened fluids consumed Method of assessment:Daily assessment of total fluid intake using graduated cupsOutcome assessors: facility staffDefinition of low fluid intake: N/R

*Mentes,12–14

2000USA

Yes Design:Cluster RCT, unblindedAim(s) examined in this review:To test the effectiveness of a two month hydration management guideline in preventing or reducing acute confusion and other hydration-linked events (HLE’s).Recruitment method, nursing homes:Methods N/R, except that a coin toss was used to randomise homes.Larger sites, residents selected from certain units. Smaller sites: selected from whole site.Recruitment method, residents:

Baseline characteristics, intervention group, n=25: Age, years, mean (SD): 80.6 (10.3)Males: 11 (44%)BMI, mean (SD): 26.1 (6.8)MMSE, mean (SD): 22.0 (5.6)NEECHAM, mean (SD): 26.4 (2.8)FIM, mean (SD): 79.4 (22.3)Baseline characteristics, control group, n=24:Age, years, mean (SD): 83.0 (9.2), p=0.41Males: 11 (46%), p=0.89 BMI, mean (SD): 27.5 (5.9), p=0.15MMSE, mean (SD): 24.6 (3.6), p=0.061NEECHAM, mean (SD): 28.3 (1.4). p=0.003FIM, mean (SD): 112.2 (10.9), p<0.001Inclusion criteria: ≥65 years

Intervention: research staff calculated personal fluid goals, based on weight, and 75% of this goal to be achieved at mealtimes. Participants provided with increased choice and availability of drinks, ‘sip-and-go’ cups and tagging of charts and trays for ‘higher-risk’ residents. Control group: routine care (not described).Both groups: care staff trained in detecting and documenting acute confusion.Duration: 8 weeks, but unclear if it was 5 or 7 days a week.

Outcome measure(s) ‡:1. Change in urine colour.2. Change in USG3. Change in fluid intake4. Number of participants achieving fluid intake of >=75% of fluid goal.5. Change in TBW.Method of assessment:1. Standard urine colour chart2. USG, assessed using Chemstrip Mini Urine AnalyserWeekly urine assessments.3. 2x 24 hour fluid intake records documented at baseline. During each week of the intervention a partial fluid intake record of drinks taken at

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Stratified sampling to obtain gender balance, details of approach N/R. Participants recruited following randomisation of homes.Setting:4 nursing homes (size: 84-717 beds). 1 smaller community home & 1 larger site in each arm of the trial.

Able to participate in baseline & outcome measuresConsent Exclusion criteria: Current acute confusionTerminal illnessCurrent uncontrolled DMGI conditions affecting transit & absorption of fluidsSevere CCFRenal failure necessitating fluid restriction or creatinine levels >=3.5mg/dlSerum Na <135mEq/lCurrent UTI

mealtimes, medication and fluid rounds, was documented. Caffeinated and alcoholic beverages were excluded. Method of assessment N/R.4. BIA-101 Quantum Analyser (RJL systems, Clinton Township). Equations referenced.BIA conducted at baseline, weeks 4 and 8.Outcome assessors: facility staffDefinition of low fluid intake and dehydration: 1. Urine colour: higher colours (7,8) indicate dehydration2. USG, mild dehydration: USG >1.020; dehydration: ≥1.025.3. Calculation of weight-based goal for fluid requirements: 100ml/kg for the first 10kg, 50ml/kg for the next 10kg, 15ml/kg for remaining body weight. Fluid intake <75% of calculated goal described as inadequate. 4. TBW normal values, 55-65% in lean to normal males; 50-60% in lean to normal females ('lean to normal' described as BMI <30.6).

Robinson,15 2002US

N/R Design:Before-afterPretest-posttest, non-randomised, uncontrolled, unblinded.Aim(s) examined in this review:To determine the effect of a hydration programme on the level of hydration and the prevention of conditions associated with dehydration.Recruitment method: N/RSetting:1 nursing home (250 beds).

Baseline characteristics, n=51:Age, years, mean: 83.5 (SD N/R), range: 66-97Males: 8 (15.7%)Number of participants with TBW lower than the standard, n (%): 24 (47)Dependency level n (%):Complete: 9 (17.6)Holds glass: 25 (49)Independent:17 (33.3)Thickened drinks: 7 (13.7)Cognition level: N/RInclusion criteria: Consent

Intervention (7 days/week, 5 weeks): Goal: to drink 8oz more fluids twice a day at mid-morning & afternoon, hydration assistant for fluid administration, colourful beverage cart, jugs & glasses, choice of 4 drinks, special requests honouredDuration: 9 weeks (2 weeks baseline, 5 weeks intervention, 2 weeks follow-up)

Outcome measure(s)3:Number of participants who always drank the extra 16 fl oz/day.Change in TBWMethod of assessment:Fluid intake monitored mid-morning & afternoon only.Use of BIA to assess TBW, methods not described, and information regarding type of machine, and equations used N/ROutcome assessors: research staffDefinition of low fluid intake and dehydration: Inadequate fluid intake defined as ≤1500mls/day

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Low TBW described as being less than ’the standard’; ‘the standard’ described as derived from the National Health & Nutrition Examination Survey.

*Schnelle,16 2010US

Yes Design:RCT, unblindedRandom numbers table usedAim(s) examined in this review:To evaluate the effects of a multi-component intervention on FI and UI incontinence in incontinent residents.Recruitment method, residents:n=495 eligible (identified by care staff)n=153 consentedn=143 baseline assessmentsn=125 randomised n=112 completed trialSetting:6 nursing homes. Size N/R.

Baseline characteristics intervention group, n=58: Age, years, mean (SD): 85.8 (9.4)Males: 16%MMSE, mean (SD): 12.9 (8.4)Sit-to-stands, number performed, mean (SD): 3.6 (3.1)Walk or wheel distance, meters, mean (SD): 58.7 (50.3)Baseline characteristics control group, n=54:Age, years, mean (SD): 86.1 (10.5), p=0.87Males:19%, p=0.68MMSE, mean (SD): 9.6 (8.4), p=0.04Sit-to-stands, number performed, mean (SD): 2.1 (2.0), p=0.004Walk or wheel distance, meters, mean (SD): 54 (55.8), p=0.66Inclusion criteria: Faecal incontinenceConsentExclusion criteria: ComatoseShort-term stay

Intervention:Conducted by research staff, every 2 hours, 7.00am – 3.30pm (3-4 residents/staff member):1. Resident checked for incontinence2. Resident offered toileting assistance3. Resident offered a choice of snack and drink4. Resident prompted to exerciseControl:Usual care (not described).Baseline & post-intervention:All participants (including controls) checked for UI & FI every 2 hours, 7.00am – 3.30pm, every weekday for 2 weeks. Toileting assistance provided when requested.Conducted by research staff.Duration: 12 weeks.

Outcome measure(s) ‡:Change in between-meal fluid intake.Method of assessment:Fluid intake assessed using validated assessment (Simmons et al, 2000)Outcome assessors: research staffDefinition of low fluid intake: N/R

*Simmons,17

2001US

Yes Design:RCT, unblindedComputerised random numbers tables used to allocate groupings following baseline assessmentsAim(s) examined in this review:To evaluate a behavioural intervention to improve fluid intake in incontinent nursing home residents (a sub-study is reported here, for those participants having blood tests for serum biochemical markers of dehydration).Recruitment method, resident:n=63 main studyn=32 participants having blood tests for serum osmolality (sub-study

Baseline characteristics, intervention group, (n=17):Age, sex and cognition N/R for this sub-group separately, but characteristics of participants in the main study intervention group (n=48) as follows:Age, years, mean (SD): 88.7 (7.1)Males: 4 (8%)MMSE score, mean (SD): 12.1 (7.9)Therapeutic or mechanically altered foods: 26 (54%)Baseline characteristic, control group (n=15):Age, years, mean (SD): 86.3 (6.1), p=0.2†

Males: 5 (33.3%), p<0.05MMSE score, mean (SD): 13.9 (6.5), p=0.38†

Therapeutic or mechanically altered foods: 9 (64%); p=0.69†

Functional ability N/R for either group.Inclusion criteria≥65 years

Intervention: usual care and x4 prompts to exercise per day and x4 prompts or help with toilet, changed if wet +:Phase 1 (weeks 1-16): x4 verbal prompts to drinkPhase 2 (weeks 17-24): x8 verbal prompts to drinkPhase 3 (weeks 25-32): x8 verbal prompts to drink, increased choice of drinks and appropriate assistance provided.Control: Usual care (not described)Duration: 5 days/week for 32 weeks

Outcome measure(s):Change in serum osmolality and BUN:creatinine ratio.Method of assessment:Venepuncture, methods not described.Definition of dehydration: Serum osmolality: >305 mOsmol/kgBUN/creatinine ratio: >20

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reported here)Setting:2 nursing homes, one for-profit, 1 not-for-profit (174 & 194 beds).

Urinary incontinenceUnderstands English or SpanishAble to respond to commands on 2 separate occasionsExclusion criteriaCatheter

Spangler,18

1984US

N/R Design:RCTc, unblindedAim(s) examined in this review:To evaluate a healthcare routine aiming to decrease incontinence and improve hydration in non-ambulatory residents.Recruitment method:All 16 non-ambulatory residents in a 30-bed unit were included, then residents matched for dehydration and incontinence levels and randomly assigned to one of two groups following baseline assessment. Not known how many were in each group.Setting:Urban, mid-west, 100-bed, proprietary nursing home.

Baseline characteristics, n=16:Age, range: 59-96Males, n (%): 2 (12.5)Cognition N/R.Inclusion criteria: Non-ambulatory

Intervention: Research Nursing Aide assigned to take a cart containing drinks (choice of juices & milk) and toileting equipment round every 1.5 hours between 06.00 and 21.00hrs (x11). Using a friendly and conversational manner, a 4oz drink was placed in the resident’s hand. If it was refused, it was returned to the cart. This was followed by an offer of help with toileting/change of pad.A 12-point checklist was completed for each contact.For the final 10 days (Phase 5), facility staff were trained to deliver the intervention.Standard Care:3-hrly checks for soiling (no offers of drinks), requests for drinks met.Duration: 50 days (10 days baseline, 10 days each crossover period, 10 days standard care for both groups, 10 days when intervention delivered by facility staff to all participants)

Outcome measure(s):Change in mean USG. Method of assessment:USG assessed using urinometer.Outcome assessors: N/RDefinition of dehydration (units N/R): 10-20: normal20-21: borderline≥22: dehydration

Tanaka,19

2009Japan

N/R Design:Before-afterPretest-posttest, non-random, uncontrolled, unblindedAim(s) examined in this review:To increase fluid intake by introducing an individualised comprehensive system of care for residents able to sit up and express wish to defecate.Recruitment method:153 residents met inclusion criteria from a total population of 1290, 31

Baseline characteristics, n=122:Age, years, mean: 85.2 (SD N/R)Males, n (%):18 (14.8)Dementia level, n (%): I (mild): 2 (1.7); II: 18 (14.9); III: 59 (48.8); IV: 42 (34.7)Dependence level, n (%): J1 & 2 (independent): 0 (0.0); A1: 7 (5.8); A2: 15 (12.4); B1: 28 (23.1); B2: 52 (43.0); C1: 7 (5.8); C3: 12 (9.9)Inclusion criteria: Ability to sit and maintain sitting positionAble to express wish to defecate

Intervention: senior nurses at each facility received training in the intervention, then trained all staff to.1. Increase fluid intake to 1500 ml/day by providing drinks early morning, between meals, and bed-time. Increased choice of drinks offered. Dedicated staff to provide drinks, verbal and physical assistance. Fluid intake recorded.

Outcome measure(s):Change in mean fluid intakeMethod of assessment:3-day mean fluid intake assessed at baseline and 12 weeks. Methods N/R.Outcome assessors: facility staffDefinition of low fluid intake: assume <1200mls, as goal for daily fluid intake = 1200-1500ml/day.

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withdrew due to declining health or discharge. Further details N/R.Setting:17 nursing homes (1290 beds)

Consent 2. Encourage complete meal intake by providing verbal and physical assistance. Intake recorded.3. Encourage urination in toilet by providing assistance.4. Reduce time spent in wet incontinence pads by checking 2 hrly and changing wet pads. Findings recorded.5. Assess when smaller incontinence pads could be used comfortably.5. Encourage time out of bed to exceed 6 hours, by keeping residents out of bed for longer, and providing social stimulation.Duration: 12 weeks

Taylor,20

2006Canada

Yes Design:RCTc, unblinded Aim(s) examined in this review:To determine whether serving 5 meals/day would improve energy and fluid intake in elderly people with dysphagia living in extended care facilities compared to 3 meals/day.Recruitment method:Not known how many screened, n=66 met entry criteria; n=37 consented, n=6 excluded prior to start of study due to change in medical condition.Setting:Extended care facility associated with an acute hospital. Size of facility N/R.

Baseline characteristics, n=31Age, years, mean (SD): 85 (6.4); range: 71-96Males: 5 (16%)Feeding assistance: 27 (87%)Pureed or minced diet: 31 (100%)BMI, mean (SD): 20.4 (3.4)Cognitive & functional ability N/RInclusion criteria: ≥65 yearsDysphagia and receiving texture-modified dietConsentExclusion criteria: Tube-feedingMedically unstableDiabetic diet

Intervention: five meals/day, matched to the 3 meals for energy content.Group 1: 5 meals/day for 4 daysGroup 2: 3 meals/day for 4 days4 weeks later:Group 1: 3 meals/day for 4 daysGroup 2: 5 meals/day for 4 daysDuration: 6 weeks

Outcome measure(s):Change in fluid intake at mealtimes. Method of assessment:Fluid defined as any food usually drunk, or is liquid at room temperature before thickening.Food and fluids not provided by hospital staff were not weighed, but recorded as % consumed. This data N/R.Outcome assessors: research dietitianDefinition of low fluid intake: N/R

Welch,21

1996US

Yes Design:Before-afterPretest-posttest, non-randomised, uncontrolled, unblinded Aim(s) examined in this review:To assess the ability of oral hydration solution to improve volume status in mildly dehydrated elderly people.Recruitment method:

Baseline characteristics, n=13:Age, years, mean: 89 (SD N/R)Males: 1 (8%)Diagnosis of dementia or AD: 9 (69%)Physical function not assessed.Inclusion criteria: ≥1 dehydration trigger on RAI-MDSSerum biochemistry indicating 'mild dehydration'§.

Intervention: Oral hydration fluids offered when standard fluid intake was less than the weight-based calculated goal for daily fluid intake (30ml/kg body weight). Method of how increased fluids were promoted not described.Duration: 5 days

Outcome measure(s):Change in serum biochemistry.Change in fluid intake.Method of assessment:Serum biochemistry assessed days 1, 3, 5.Fluid intake assessed daily, methods N/R.

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Two-stage screening:1. Using RAI-MDS, residents identified with ≥1 dehydration/fluid maintenance trigger present.2. Serum biochemistry to identify those with fluid defecit4.Setting:Nursing home (265 beds)

ConsentExclusion criteria:Serum osmolality, mOsm/kg: ≥300BUN, mg/dl: ≥50Serum Na, mEq/l: ≥155Serum creatinine, mg/dl: ≥3.5Diabetes MellitusCCFDiabetes Insipidus

Outcome assessors: N/RDefinition of low fluid intake: Mild dehydration using serum biomarkers not defined, but standard values reported: Serum osmolality, mOsm/kg: 275-300BUN, mg/dl: 5-20Serum Na, mEq/l: 140-149Serum creatinine, mg/dl: 0.7-1.5Inadequate daily fluid intake defined as intake < calculated goal.

*Willms,22

2003Germany

N/R Design:Before-afterPretest-posttest, non-randomised, uncontrolled, unblinded Aim(s) examined in this review:Residents requiring nursing care should receive a daily fluid intake of 1.3l/day, as recommended by the German Nutrition Society guidelines. Recruitment method:Of 181 residents, n=157 requiring nursing care, stage 1-3. n=10 were selected from each unit, every 2nd person on the resident list, until 10 people obtained from each of the 7 units.Setting:1 nursing home (7 units, number of beds N/R)

Baseline characteristics, n=70: Age, range, n (%):64–69, n= 5 (2.8)70–79, n=36 (19.9)80–89, n=82 (45.3)90–99, n=57 (31.5)>100, n= 1 (0.6)Males, n (%): 24 (13.3)Care level 1, n (%): 10 (14.7)Care level 2, n (%): 37 (54.4)Care level 3, n (%): 21 (30.9)Cognition level: N/RInclusion criteria: Residents requiring care (stages 1-3)Exclusion criteria: Nursing care stage 0 (independent)Enteral feedingMedical reason for limited fluid intake

Baseline: 10 daysIntervention (duration N/R): education for staff and residents, provision of water fountains, drinks delivered at set times, increased choice of drinks taking into account colour and taste, increased assistance such as handing drinks to residents, thickening of drinks if required and use of drinking aids (heavy cups with specially designed handles for participants with Parkinson’s disease)Follow-up period: 10 daysDuration: N/R

Outcome measure(s):Change in mean fluid intake.Method of assessment:Fluid intake assessed daily by nursing home staff using calibrated containers.No information provided regarding time period (whole or part of day).Outcome assessors: facility staffDefinition of low fluid intake: <1.3l/day.

Zembrzuski,23

2006US

Yes Design:CCT, unblindedAim(s) examined in this review:To investigate whether assistance and encouragement to increase oral fluids resulted in an increase in fluid intake and a decrease in postural hypotension and falls in skilled nursing facilities (SNF’s)Recruitment method, residents:n=337 residents meeting criteria identified by senior nurses, n=98 consented

Baseline characteristics, intervention group, n=48: Age, years, mean (SD): 88.04 (6.35)Males: 9 (18.8%)MMSE: mean (SD), range: 20.88 (5.99), 7-30Physical function N/RBaseline characteristics control group, n=34:Age, years, mean (SD): 85.76 (7.33), p=0.14†

Males: 5 (14.7%), p=0.63†

MMSE: mean (SD), range: 15.53 (9.18), 0-29, p=0.003†

Physical function N/RInclusion criteria: >75 yearsAble to weight bear or sit upright ≥1 minute

Intervention: between-meal drinks offered at least twice daily, residents offered a choice, encouraged and prompted to drink. Residents who refused were asked a 2nd time. Senior nurse informed of any residents drinking <500mls by 4.30pm. Implemented by research staff.Control: routine care described as following the general standard for offering drinks, drinks provided on request, increased drinks for 'at

Outcome measure(s)‡:Change in mean fluid intake.Method of assessment:Fluid intake observed over 12 hour period for 3 days prior to study commencement and for 3 days at the end of the intervention using graduated cups.Outcome assessors: research staffDefinition of low fluid intake: Inadequate fluid intake described using one of three calculations:1. <30ml/kg body weight

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Recruitment method, care homes & setting:21 SNF’s approached, 4 participated (2 intervention). Size, 120-226 beds.

Able to express rejection/acknowledgement of fluids offeredConsentExclusion criteria: Diet to alter fluid balanceDysphagiaEnteral or parenteral feedingInfectionsCCFEnd of lifeTransfer out of facilityRecent bereavement or other anxiety

risk' residents.Duration: 30 days

2. <1500mls/24hr3. <100ml/kg/body weight for first 10kg, then 50ml/kg for second 10kg, then 15ml/kg for remaining body weight.

*Author contacted to request further information†p values calculated by reviewers.‡Secondary outcomes for this study described & reported in Web Tables 4 and 5.§It is unclear how serum biochemistry values have been used to determine study eligibility between the abstract, text, Table 1 and Table 4.

Abbreviations: AD=Alzheimer’s Disease; ADL=Activities of Daily Living; BIA=Bioelectrical Impedance Analysis; BMI=Body Mass Index; BUN=Blood Urea Nitrogen; DM=Diabetes Mellitus; CCF=Congestive Cardiac Failure; CCT=Controlled Clinical Trial; CPS=Cognitive Performance Scale; FI=faecal incontinence; FIM=Functional Independence Measure; GI=gastrointestinal; Hb=Haemoglobin; MMSE=Mini Mental State Examination; MNA=Mini Nutritional Assessment; Na=Sodium; N/R=Not Reported; NEECHAM=Neelon and Champagne Confusion Scale; ONS=Oral Nutritional Supplements; RAI-MDS=Resident Assessment Instrument–Minimum Data Set; RCT=Randomised Controlled Trial; RCTc=Randomised Controlled Trial, crossover; RIP=Rest in Peace (died); SD=Standard Deviation; SPMSQ=short portable mental status questionnaire; SNF=skilled nursing facilities; TBR=Total Body Resistance; TBW=Total Body Water; UI= urinary incontinence USG=Urine Specific Gravity; UTI=Urinary Tract Infection.

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WEB Table 2: Characteristics of included studies, full details of observational studies

Study details Ethical review?

Study design, aims and methods Participants, selection & baseline characteristics Type of exposure (independent variables) examined in this review

Outcome measure(s)(dependant variable/s)

& Measure of dehydration / fluid intake

Dyck,24,25 2006US

Yes Design:Cross sectional2o analysis of the RAI-MDS & OSCAR databases Aim(s) examined in this review:To examine the relationship between nursing staffing and dehydration in nursing home residents.Setting:2951 nursing home facilities, 6 mid-west US states.All Medicare and Medicaid nursing home facilities. Facilities with <30 beds excluded.

Baseline resident characteristics, n=363,895:Age, years, mean (SD): 83.9 (7.9), range: 65-112Males: 99,612 (27.3%)Cognition and physical function N/RBaseline nursing-home characteristics, n=2951Government-owned: 169 (5.7%)Non-profit: 782 (26.5%)For-profit: 2000 (67.8%)Chain facilities: 1648 (55.9%)Urban: 1967 (66.7%)Case Mix Index: mean (SD): 97.2 (10.7)RN, HRD, mean (SD): 0.35 (0.21)LPN, HRD, mean (SD): 0.63 (0.28)CNA, HRD, mean (SD): 1.95 (0.54)All staff grades, combined: 2.93 (0.73)Inclusion criteria, residents: All residents were included from an included facility.

Type of ownership (for profit, not for profit, government-owned)Reimbursement methodFacility location (urban, rural)Case mix indexStaffing, HRD by grade of staff (CNA, LN, RN)

Outcome measure(s):To evaluate risk of dehydration according to facility and/or staffing factors.Method of assessment & definition of dehydration:Dehydration present/absent, as defined by ICD-9-CM diagnostic code of 276.5, or as defined by the RAI-MDS J1c, ≥2 criteria present from the following:Fluid intake <1.5l/dayClinical signs of dehydrationFluid loss > fluid intake.Methods used to assess RAI-MDS criteria N/R.Numbers of participants diagnosed using each method N/R.

Gaspar,26,27

1999US

Yes Design:Cross sectionalAim(s) examined in this review:To investigate modifiable factors associated with inadequate water intake.Recruitment method:Convenience sampleSetting:2 rural nursing homes in South Dakota (79 and 60 beds) and 1 urban nursing home in Utah (98 beds).

Baseline resident characteristics, n=99:Age, years, mean: 85 (SD N/R) Males: 23 (23.2%)Able to respond to interview questions: 51 (51.5%)Sensory function, impaired: 40 (40%)Norton score*, mean: 15 (SD N/R); range: 7-20Inclusion criteria:≥70 yearsExclusion criteria:Fluid restrictionsTube feeds

Number of ingestion sessionsWho initiated the ingestionPlace of ingestionPositioning of resident’s upper body and head during feeding

Outcome measure(s):Mean total water intake (from food and fluids).Method of assessment :Observations of food and fluid intake for 2x24hr periods during one week. Coding manual used to code water content of foods and fluids.Outcome assessors: research staffDefinition of low fluid intake: Inadequate water intake (from food and fluids) defined as ≤1600ml/m2 body surface area per 24 hours

McGregor,28

2006Canada

Stated as not required

Design:Retrospective cohort Aim(s) examined in this review:To determine whether acute hospital admission rates from extended care facilities due to dehydration were effected by type of facility ownership, after adjusting for case-mix and other individual and facility-level

n=43,065Not for profit extended care facilities, n=30,932:Age, years, mean (SD): 82.2 (9.7)Males:10,788 (34.9%)Care level, n (%): I/II: 10,908 (35.3); III: 7468 (24.1); Extended: 12,556 (40.6)For profit extended care facilities, n=12,133:Age, years, mean (SD): 82.3 (9.0)Males: 3969 (32.7%)

Not-for-profit facilities, sub-groups:Facility attached to hospital, n=66Amalgamated to health authority, n=21Single-site facilities, n=104Multi-site facilities, n=21For-profit facilities, sub-

Outcome measure(s):Risk of admission to acute unit from a care facility due to dehydration as a primary diagnosisMethod of assessment & definition of dehydration:ICD-9 coding: E276.5

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Study details Ethical review?

Study design, aims and methods Participants, selection & baseline characteristics Type of exposure (independent variables) examined in this review

Outcome measure(s)(dependant variable/s)

& Measure of dehydration / fluid intake

characteristics, between 01/04/1996-01/08/1999.Recruitment method:British Columbia linked health databaseSetting:301 extended care facilities (212 not-for-profit; 89 for-profit)

Care level, n (%): I/II: 5154 (42.5); III: 4621(38.1); Extended: 2358 (19.4Inclusion criteria: At least one day spent in nursing home with complete data, 01/04/1996-01/08/1999Exclusion criteriaRespite care

groups:Chain facilities, n=14Multi-site facilities, n=38Single-site facilities, n=37

Reed,29

2005USA

Yes Design:Cross sectionalAim(s) examined in this review:To assess resident, staff and environmental characteristics associated with low fluid intake.Recruitment method, care homes:Purposive sampling of care homes, representing size, financing, type, case mix and care provision.Recruitment method, residents:575 approached (2-4 residents from facilities <16 beds; 13-19 residents from facilities >16 beds)407 participated, main study326 included in fluid-intake analysesSetting:10 nursing homes and 35 RC/AL†

Baseline characteristics reported for main study, n=407 (not reported separately for the sub-study, n=326 reported in in this review):Age, years, mean: 85 (SD N/R)Males: 85 (21%)Cognitive impairment (%): Very severe, 37%; Severe, 27%; Moderate, 25%; Mild,12%Physical function N/RInclusion criteria: ≥65 yearsDementia diagnosisConsentExclusion criteriaHuntingdon’s diseaseAlcohol-related dementiaSchizophreniaMental retardationManic depression

Staff:resident ratioType of staff training re hydration and nutritionFacility environmentFacility type and ownershipNew model RC/AL v ‘traditional’ model†

Outcome measure(s):To evaluate low fluid intake according to facility type, facility environment and staffing factors.Method of assessment & definition of dehydration:Low fluid intake defined as an intake of <8 fl oz, assessed over a single observed meal-time (method of assessment not described).

*Norton Score used in this study to assess general physical and mental function, but it was validated to assess risk for development of pressure sores; possible scores range from 4-20. <9 =very high risk of developing pressure sores (due to impaired cognition, physical activity and bladder control); 10-13=high risk; 14-17=medium risk and 18-20=low risk.†Residential/assisted living facilities (RC/AL) are non-nursing home settings which provide room, board and assistance with activities of daily living. New model RC/AL offers add-on services for residents requiring more care and/or nursing care.

Abbreviations: CNA=Certified Nursing Assistant; HRD=Staffing hours/resident/day; LPN=, Licenced Practical Nurse; NH=Nursing home; N/R=not reported; OSCAR=Online Survey, Certification & Reporting (OSCAR) database; RAI-MDS=Resident Assessment Instrument–Minimum Data Set; RC/AL=residential/assisted living facilities; RN=Registered Nurse; SD=standard deviation; US=United States of America

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Web Table 3: Findings from included intervention studies

Author Study Design

Outcome measures, baseline levels Outcome measures, results p Comments

Allen,2011UK

RCTn=24

N/A Results reported by authors proportion of ONS consumed per number of drinks served, mean (SD):Group 1 (straw in bottle): 0.62 (0.4)Group 2 (beaker): 0.81 (0.29)Results re-analysed by reviewers as proportion of ONS consumed, per participant, mean (SD):Group 1 (straw in bottle): 0.62 (0.4)Group 2 (beaker): 0.81 (0.29)

0.002

0.23

Allison, 2005US

Before-afterPretest-posttestn=281 (results reported for 198)

TBR, ohms, mean (SD): 610.2 (36.6)

TBR, ohms, mean (SD): 478.4 (59.9)

<0.001 Results reported for 198 participants. The remaining 83 participants described as having the same or higher baseline TBR readings at the end of the study, but TBR was assessed later at 5-6 months & that the intervention was not closely adhered to in this group.

Cleary,2008.Canada

Before-afterPretest-posttestn=3

Fluid intake, % consumed, mean (SD): 62.7 (29.2)

% fluid intake, mean (SD): 77.8 (29.9)

0.53 Figures N/R in text, extracted from graph independently by 2 reviewers. p calculated by reviewers

Dunne,2004US

Before-afterPretest-posttestStudy 1: n=9Study 2: n=9

Study 1, fluid intake, % of fluids offered, mean (SD):High-contrast red tableware (n=9): 54.4 (36.6)Study 2, fluid intake, % of fluids offered, mean (SD):High-contrast blue (n=9): 77 (34).Low-contrast red (n=7): 88 (25)Low-contrast blue (n=6): 88 (25)

Study 1, fluid intake, % of fluids offered, mean (SD): 87.7(22.1)Study 2, fluid intake, % of fluids offered, mean (SD):High-contrast blue (n=9): 92 (21)Low-contrast red (n=7): 88 (25)Low-contrast blue (n=6): 90 (22)

0.02

0.261.000.88

Study 1: p value recalculated by reviewers (reported p value: 0.001).Study 2: p values calculated by reviewers

Fries,1997US

Before-afterPretest-posttestPre-RAI, n=2128Post-RAI, n=2088

Pre-RAI implementation:No. participants with dehydration at baseline: 60 (3%)No. participants with dehydration at baseline remaining at the care home AND improved from baseline to 6 months: n=2

No. participants, dehydration absent at baseline remaining at the care home AND developed dehydration at 6 months: N/R

Post RAI implementation: No. participants with dehydration at baseline: 22 (1%) No. participants with dehydration at baseline remaining at the care home AND improved from baseline to 6 months, n=4; OR, pre v post-RAI: 0.06No. participants dehydration absent at baseline remaining at the care home AND developed dehydration at 6 months: N/R; OR pre v post-RAI: 1.08

0.01

0.008

0.82

Prevalence of dehydration differs between the text (3%) and Table 2 (2%). As prevalence is definitively described as n=60 (3%) in the text, this figure is reported in this review.

Holzapfel,1997US

RCTc,n=39

Mean fluid intake:N/R

Actual mean fluid intakes:N/R

0.533-1.00

Results presented as the t statistic and p value for between-group comparisons on days 1,5,10,15,20.

Kenkman, Cluster CCT Dehydration, n (%): Dehydration, n (%): Discrepancy between Table 3 & text.

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Author Study Design


2010UK

n=56 Intervention: 5 (16); Control: 12 (46) ; p=0.02 (p value calculated by reviewers)

Intervention: 3 (9); Control: 10 (39)RR of dehydration, intervention v control: 0.36 (95% CI: 0.06, 2.04)

0.25 Numbers taken from text, as these correspond to reported RR of 0.36.

Lin,2013Taiwan

Cluster CCTn=74

Mean (SD) fluid intake, mls/day:Intervention: 1449 (421); Control: 1539 (565), p=0.436USG, mean (SD’s N/R): Intervention: 1.009; Control:1.012 (p value N/R)

Mean (SD) fluid intake, mls/day:Intervention: 1732 (301); Control: 1548 (558)USGN/R

0.107Post-intervention USG results N/R, but text stated that mean USG remained unchanged in both groups

McCormick2006Ireland

RCTcn=11

Mean fluid intake:N/R

Mean (SD) fluid intake:Thickened at bedside: 783 (165)Commercially-prepared, pre-thickened: 902 (271) 0.21

p value recalculated by reviewers (reported p value: 0.47).8 (73%) participants increased fluid intake with commercially-prepared pre-thickened fluids

Mentes, 2000US

Cluster RCTn=49

24 hour fluid intake, mls, mean (SD’s N/R): Intervention: 1654; Control: 1888 (p value N/R)No. participants fluid intake >75% of fluid intake goal: Intervention: 19 (76%); Control: 22 (92%), p=0.247Urine colour, mean (SD): Intervention: 2.2 (1.6); Control: 2.6 (1.2), p=0.12USG, mean (SD): Intervention: 1.0159 (0.0041); Ctrl: 1.0195 (0.0038), p=0.002TBW, %, mean (SD): Intervention: 54.68 (8.73); Control: 51.43 (6.16). p=0.14

24 hour fluid intake, mls, mean (SD’s N/R): Actual fluid intakes not reported.No. participants fluid intake >75% of fluid intake goal: Intervention: n=22 (88%); Control: n=20 (83%)Urine colour, mean (SD): Intervention: 2.0 (1.5); Control: 2.5 (1.5)USG, , mean (SD)::Intervention:1.0156 (0.0049); Control: 1.0164 (0.0045)TBW, %, mean (SD): Intervention: 53.90 (8.14); Control: 51.46 (7.11)

0.64

0.24

0.55

0.28

p values for post-intervention calculated by reviewers

TBW: means, SD's & p values calculated by reviewers

Robinson, 2002US


No. participants TBW lower than the standard, n (%): 24 (47)No. participants always drinking extra 16 fl oz/day: N/A

No. participants TBW lower than the standard, n (%): 3 (6)No. participants always drinking extra 16 fl oz/day: 27 (53%)

0.001

N/R

Mean TBW values reported graphically, but labelling unclear, so unable to ascertain figures. Text states that all 3 participants with TBW lower than the standard did not always drink the extra 16oz, had difficulty swallowing and needed help from the hydration assistant

Schnelle, 2010US

RCTn=112

Between-meal fluid intake, fl oz/day, mean (SD):Intervention: 0.66 (0.22); Control: 72 (0.18), p=0.92

Increase in between-meal fluid intake, fl oz/day, mean (SD):Intervention: +13.5 (6.5); Control: +1.9 (4.0)

<0.001 Text states meal-time fluid intake did not decrease, so increase seen between meals was a net gain.

Simmons,2001US

RCTn=32

Serum osmolality, mOsmol/kg, mean (SD): Intervention: 303.6 (9.1); Control: 303.4 (8.5), p=0.95BUN: creatinine ratio, mean (SD): Intervention: 24.0 (4.6); Control: 21.7 (6.1), p=0.23

Serum osmolality, mOsmol/kg, mean (SD):Intervention: 297.0 (10.8); Control: 294.7 (11.9)BUN:creatinine ratio, mean (SD):Intervention: 22.9 (5.6); Control: 23.8 (7.2)

0.57

0.71

p values calculated by reviewers.This study also assessed meal-time and between-meal fluid intake, but results not fully reported.

Spangler,1984US

RCTcn=16

USG ≥20, n (%): 4 (25)

USG ≥20, n (%): 0 (0%)USG, mean (units N/R):

Mean urometer readings extracted from graph, SD's N/R.t test for repeated measures to

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Author Study Design


Group A v B:Phase 1 (both groups, usual care): 20 v 18Phase 2 (Group A, intervention): 14 v 18.5Phase 3 (Group B, intervention): 17 v 13Phase 4 (both groups, usual care): 17 v 16Phase 5 (both groups, intervention): 14.5 v 14

<0.002

compare groups A and B in phases 2 and 3, described as being significant, but only the p value was reported

Tanaka, 2009Japan


Fluid intake, mls per day, mean (SD): 881.1 (263.8)

Fluid intake, mls per day, mean (SD): 1146.4 (365.2) <0.001

Taylor,2006Canada

RCTcn=31

N/A Meal-time fluid intake, mls, mean (SD): 3 meals/day: 612 (176); 5 meals/day: 698 (156)Meal-time fluid content of food, mls, mean (SD): 3 meals/day: 1116 (387); 5 meals/day: 1148 (330)

0.003

0.73

Text stated that fluids offered between-meals did not displace fluid consumption at meals. This data N/R.

Welch, 1996US


Serum osmolality, mOsm/kg, mean (SD): 285.38 (1.73)BUN, mg/dl, mean (SD): 25.08 (2.78)Serum Na, mEq/l, mean (SD): 141.15 (0.93)Oral hydration fluid, water, other fluids, total fluid intake, mls, mean (SD): 0 (0), 397 (67), 1191 (166), 1588 (SD N/R)

Serum osmolality, mOsm/kg, mean (SD): 278.77 (1.59)BUN, mg/dl, mean (SD): 21.62 (2.92)Serum Na, mEq/l, mean (SD): 138.62 (0.84)Oral hydration fluid, water, other fluids, total fluid intake, mls, mean (SD): 131 (88), 420 (10), 1131 (126), 1682 (SD N/R)

<0.001

0.002

<0.001

p values calculated by reviewers.

Willms,2003Germany


Fluid intake, mls/day, mean (SD): 956 (413)

Fluid intake, mls, mean (SD): 1325 (373) <0.001

2 residents not available for baseline assessment, n=68

Zembrzuski, 2006USA

CCTn=82

Fluid intake, mls: mean (SD):Intervention: 1078 (183); Control: 1118 (285), p=0.47

Fluid intake, mls: mean (SD):Intervention: 1577 (66); Control: 1063 (274) <0.001

p value calculated by reviewers.

Abbreviations: BUN=Blood Urea Nitrogen; fl oz/day=fluid ounces per day; Na=Sodium; N/R=Not Reported; ONS=Oral Nutritional Supplements; RAI-MDS=Resident Assessment Instrument–Minimum Data Set; RR=Relative Risk; TBR=Total Body Resistance; TBW=Total Body Water; USG=Urine Specific Gravity

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Web Table 4: Before-after Pretest-posttest and crossover intervention studies reporting additional outcomes, considered as secondary outcomes in this review

Study details

Secondary outcome Pre-intervention levels for secondary outcomes

Post-intervention levels for secondary outcomes

pMcCormick,2011Ireland

Number of participants constipated, n (%)n=11N/R

n=11Rates of constipation N/R, but described as not being significantly different.

Robinson,2002US

Number of fallsNumber of UTI'sNumber of URTI'sSkin breakdown, number of occurrencesNumber of bowel movementsLaxative useEpisodes of mental status changes:

n=51

Unit of measurement and baseline rates not reported

Results reported descriptivelyDecline in number of fallsFewer observed UTI’sFewer observed URTI’sFewer observed occurrences of skin breakdownNumber of bowel movements increasedReduction in laxative useEpisodes of mental status, changes not reported

0.05nsnsns0.040.05

Abbreviations: BMI=Body Mass Index; BP=Blood Pressure; CI=Confidence Interval; DBP=Diastolic Blood Pressure; Hb=Haemoglobin; HLE=Hydration-Linked Events; N/R=Not Reported; MMSE=Mini Mental State Examination; n=number of participants; ns=not significant; RR=Relative Risk; SBP=Systolic Blood Pressure; SD=Standard Deviation; URTI=Upper Respiratory Tract Infection; UTI=Urinary Tract Infection.

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Web Table 5: Controlled intervention studies reporting additional outcomes, considered as secondary outcomes in this review

Study details

Secondary outcome Baseline levels of secondary outcomes Findings for secondary outcomes

InterventionGroup

ControlGroup

p Intervention

Group

ControlGroup

p

Kenkman,2010UK Falls, number of residents falling in previous 12 months, n (%)

BMI, mean (SD)MMSE, mean (SD)UTI's, number of residents with UTI in previous 12 months, n (%)URTI's, number of residents with URTI in previous 12 months n (%)Anaemia (Hb <12g/dl), n (%)

n=57

34 (60)25.75 (5.32)19 (5.6), n=3021 (37)20 (35)5 (38.5), n=13

n=48

27 (56)24.68 (4.49), n=4317 (6.2), n=2620 (42)10 (21)2 (29), n=7

0.73*

0.28*

0.21*

0.61*

0.11*

0.66*

34 (60)25.62 (4.82)17 (6.2)20 (35)16 (28)6 (46)

24 (50)24.3 (4.82), n=4315 (7.9)12 (25)22 (46)4 (57)

0.23*

0.18*

0.3*

0.27*

0.06*

0.63*

Lin,2012Taiwan Number of participants with asymptomatic bacteriuria (ASB), n (%)

n=44

17 (38.6)

n=30

5 (16.7) 0.042 10 (22.7) 3 (10) 0.218

Mentes,2000US Acute confusion, number of events, n (%)

UTI, number of events, n (%)URTI, number of events, n (%)Pneumonia, number of events, (%)Influenza, number of events, n (%)History of infections, n (%) (time period over which infections occurred N/R)

n=25

Baseline rates N/R

9 (36)

n=24

Baseline rates N/R

2 (8.3) 0.02

0001 (4)2 (8)

2 (8.3)2 (8.3)2 (8.3)1 (4.1)0

RR (95% CI) for all HLE's combined: 0.48 (0.18, 1.26).

Schnelle,2010US Constipation, number of participants, n (%)

n=58

45 (77.5)

n=54

44 (81.5) 0.61 30 (51.7) 51 (94.4) <0.001

Zembrzuski,2006US Number of residents falling in previous 30 days, n (%)

SBP, mean (SD) difference between 3 readings of supine and 3 readings of upright BP DBP, mean (SD) difference between 3 readings of supine and 3 readings of upright BP

n=48

13 (27)

10.8 (5.61)

4.06 (5.81)

n=34

3 (9)

7.37 (4.66)

2.74 (2.51)

0.05*

0.003*

0.16*

3 (6)

1.48 (7.29)

-1.91 (4.63)

6 (18)

7.50 (7.63)

2.51 (5.78)

0.12*

0.003*

0.0002*

*p values calculated by reviewers

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