Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people.

BACKGROUND: There is evidence that water-loss dehydration is common in older people and associated with many causes of morbidity and mortality. However, it is unclear what clinical symptoms, signs and tests may be used to identify early dehydration in older people, so that support can be mobilised to improve hydration before health and well-being are compromised. OBJECTIVES: To determine the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs and tests to be used as screening tests for detecting water-loss dehydration in older people by systematically reviewing studies that have measured a reference standard and at least one index test in people aged 65 years and over. Water-loss dehydration was defined primarily as including everyone with either impending or current water-loss dehydration (including all those with serum osmolality ≥ 295 mOsm/kg as being dehydrated). SEARCH METHODS: Structured search strategies were developed for MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, LILACS, DARE and HTA databases (The Cochrane Library), and the International Clinical Trials Registry Platform (ICTRP). Reference lists of included studies and identified relevant reviews were checked. Authors of included studies were contacted for details of further studies. SELECTION CRITERIA: Titles and abstracts were scanned and all potentially relevant studies obtained in full text. Inclusion of full text studies was assessed independently in duplicate, and disagreements resolved by a third author. We wrote to authors of all studies that appeared to have collected data on at least one reference standard and at least one index test, and in at least 10 people aged ≥ 65 years, even where no comparative analysis has been published, requesting original dataset so we could create 2 x 2 tables. DATA COLLECTION AND ANALYSIS: Diagnostic accuracy of each test was assessed against the best available reference standard for water-loss dehydration (serum or plasma osmolality cut-off ≥ 295 mOsm/kg, serum osmolarity or weight change) within each study. For each index test study data were presented in forest plots of sensitivity and specificity. The primary target condition was water-loss dehydration (including either impending or current water-loss dehydration). Secondary target conditions were intended as current (> 300 mOsm/kg) and impending (295 to 300 mOsm/kg) water-loss dehydration, but restricted to current dehydration in the final review.We conducted bivariate random-effects meta-analyses (Stata/IC, StataCorp) for index tests where there were at least four studies and study datasets could be pooled to construct sensitivity and specificity summary estimates. We assigned the same approach for index tests with continuous outcome data for each of three pre-specified cut-off points investigated.Pre-set minimum sensitivity of a useful test was 60%, minimum specificity 75%. As pre-specifying three cut-offs for each continuous test may have led to missing a cut-off with useful sensitivity and specificity, we conducted post-hoc exploratory analyses to create receiver operating characteristic (ROC) curves where there appeared some possibility of a useful cut-off missed by the original three. These analyses enabled assessment of which tests may be worth assessing in further research. A further exploratory analysis assessed the value of combining the best two index tests where each had some individual predictive ability. MAIN RESULTS: There were few published studies of the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs or tests to be used as screening tests for detecting water-loss dehydration in older people. Therefore, to complete this review we sought, analysed and included raw datasets that included a reference standard and an index test in people aged ≥ 65 years.We included three studies with published diagnostic accuracy data and a further 21 studies provided datasets that we analysed. We assessed 67 tests (at three cut-offs for each continuous outcome) for diagnostic accuracy of water-loss dehydration (primary target condition) and of current dehydration (secondary target condition).Only three tests showed any ability to diagnose water-loss dehydration (including both impending and current water-loss dehydration) as stand-alone tests: expressing fatigue (sensitivity 0.71 (95% CI 0.29 to 0.96), specificity 0.75 (95% CI 0.63 to 0.85), in one study with 71 participants, but two additional studies had lower sensitivity); missing drinks between meals (sensitivity 1.00 (95% CI 0.59 to 1.00), specificity 0.77 (95% CI 0.64 to 0.86), in one study with 71 participants) and BIA resistance at 50 kHz (sensitivities 1.00 (95% CI 0.48 to 1.00) and 0.71 (95% CI 0.44 to 0.90) and specificities of 1.00 (95% CI 0.69 to 1.00) and 0.80 (95% CI 0.28 to 0.99) in 15 and 22 people respectively for two studies, but with sensitivities of 0.54 (95% CI 0.25 to 0.81) and 0.69 (95% CI 0.56 to 0.79) and specificities of 0.50 (95% CI 0.16 to 0.84) and 0.19 (95% CI 0.17 to 0.21) in 21 and 1947 people respectively in two other studies). In post-hoc ROC plots drinks intake, urine osmolality and axillial moisture also showed limited diagnostic accuracy. No test was consistently useful in more than one study.Combining two tests so that an individual both missed some drinks between meals and expressed fatigue was sensitive at 0.71 (95% CI 0.29 to 0.96) and specific at 0.92 (95% CI 0.83 to 0.97).There was sufficient evidence to suggest that several stand-alone tests often used to assess dehydration in older people (including fluid intake, urine specific gravity, urine colour, urine volume, heart rate, dry mouth, feeling thirsty and BIA assessment of intracellular water or extracellular water) are not useful, and should not be relied on individually as ways of assessing presence or absence of dehydration in older people.No tests were found consistently useful in diagnosing current water-loss dehydration. AUTHORS' CONCLUSIONS: There is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicate water-loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a high proportion of people with dehydration, and wrongly label those who are adequately hydrated.Promising tests identified by this review need to be further assessed, as do new methods in development. Combining several tests may improve diagnostic accuracy.

Effectiveness of a home hazard modification program for reducing falls in urban community-dwelling older adults: A randomized controlled trial.

AIM: To evaluate the potential improvement of fall prevention awareness and home modification behaviors and to decrease indoor falls by applying a home hazard modification program (HHMP) in community-dwelling older adults followed up to 1 year in this randomized controlled trial. METHODS: The present authors randomly assigned 130 older adults living in the Tokyo metropolitan region to either the HHMP intervention group (n = 67) or the control group (n = 63). Both groups received four, 2 h fall prevention multifactorial programs including education regarding fall risk factors, food and nutrition, foot self-care, and exercise sessions. However, only the HHMP group received education and practice regarding home safety by using a model mock-up of a typical Japanese home. RESULTS: The mean age of the HHMP group was 75.7 years and the control group 75.8. The HHMP group showed a 10.9% reduction in overall falls, and falls indoors showed an 11.7% reduction at 52 weeks. Those aged 75 years and over showed a significant reduction in both overall falls and indoor falls at 12 weeks. Fall prevention awareness and home modifications were significantly improved in the HHMP group. CONCLUSION: HHMP has the potential to improve fall prevention awareness and home modification behaviors, and specifically decreased overall and indoor falls in 12 weeks in those aged 75 years and older in community-dwelling older adults.

Systematic review and meta-analysis of studies involving telehome monitoring-based telenursing for patients with chronic obstructive pulmonary disease.

AIM: This systematic review evaluated the effects of telehome monitoring-based telenursing (THMTN) on health outcomes and use of healthcare services and compared them with the effects of conventional treatment in patients with severe and very severe chronic obstructive pulmonary disease (COPD). METHODS: An extensive published work search of several databases was performed in May and October 2011. Randomized controlled trials and non-randomized controlled clinical trials were evaluated. Parameters included hospitalization rate, number of visits to the emergency department, exacerbations, mean number of hospitalizations, mean duration of bed days of care, mortality, and health-related quality of life by the duration of THMTN and COPD severity. A random effects model was applied. Risk ratio and mean difference were calculated. Heterogeneity was assessed using the I(2) statistic. RESULTS: Nine original articles involving 550 participants were identified in the meta-analysis. THMTN decreased hospitalization rates, emergency department visits, exacerbations, mean number of hospitalizations, and mean duration of bed days of care in severe and very severe COPD patients. Hospitalization rates and emergency department visits were comparable between patients undergoing THMTN of different durations. In addition, THMTN had no effect on mortality. CONCLUSION: THMTN significantly decreases the use of healthcare services; however, it does not affect mortality in severe and very severe COPD patients.

Six month outcomes of an innovative weekly intergenerational day program with older adults and school-aged children in a Japanese urban community.

AIM: To describe the nature of the progression of intergenerational interactions among and between older people and children in a weekly intergenerational day program (IDP) in an urban community and to evaluate the older people's health-related quality of life (HRQOL) and depressive symptoms, compared to the program volunteers, as well as the children's perspectives of older people, during the first 6 months of the program's implementation. METHODS: This longitudinal study, with a convenience sample of older people (n = 14), program volunteers (n = 8), and school-aged children (n = 7), used mixed methods to analyze the results. Participant observations and interviews were used to describe the interactions between the generations over the 6 months. An ANOVA with repeated measures was used to determine the statistical effects over time (initially and at 3 months and 6 months) for HRQOL (Medical Outcomes Study 8-Item Short-Form Health Survey) and depression (Geriatric Depression Scale, GDS-15). Semantic differential scales identified the children's perspectives of older people. RESULTS: The intergenerational interactions were grouped into thirteen categories; for example, "The IDP provided a meaningful sense of place." The quality of life in relation to the mental health of the older people's group improved significantly between the first involvement and after 6 months, while the GDS-15 scores significantly decreased at the three time points in the more depressed older people's subgroup. The children's initial generally positive perspectives of older people showed no statistically significant change over time. CONCLUSION: The intergenerational interactions in the IDP yielded a meaningful place for both generations, improved the HRQOL of the older people's group, and decreased the depressive symptoms in the more depressed older people's subgroup.