619
In oduc ion
Declining bi h a es and inc eased li e expec ancy ha e
subs an ially aised he p opo ion o elde ly people in he
popula ion and he o al numbe o olde people a ound
he wo ld and hese ends a e expec ed o con inue (1).
Wo ldwide, hose aged 60 yea s and o e a e he as es
g owing segmen o he popula ion and hose o e 80 yea s a e
he as es g owing g oup (1).
The elde ly popula ion has a high a e o ch onic illness
(2) and is mo e ulne able o disease. People aged 65 and
o e ha e mo e hospi al s ays han any o he g oup. Ageing
popula ions will he e o e place e en g ea e demands on social
and heal h se ices a ound he wo ld (1).
Dehyd a ion is he mos common elec oly e diso de
among elde ly pa ien s. I is widely p e alen and cos ly
o indi iduals and o he heal h ca e sys em (3). Acco ding
o U. S. s a is ics, $1.36 billion was spen in 1996 o ea
hospi alized elde ly pa ien s wi h dehyd a ion as hei p ima y
diagnosis (4). Pa icula ly dehyd a ion o en leads o poo
heal h and medical ou comes; inc eased hospi aliza ion,
and inc eased usage o long e m ca e (LTC) acili ies. I is
associa ed wi h signi ican ly longe s ays in ehabili a ion
se ings and con ibu es o he de elopmen o ch onic diseases
(5).The e o e because o i s high incidence o cases among
he elde ly, small inc eases in i s p e alence can ansla e o
subs an ial impac s a he popula ion-le el.The p esen a icle is
a e iew o he li e a u e o dehyd a ion among he hospi alized
elde ly popula ion, wi h a main ocus on economic bu den.
Me hods
Sea ch s a egies
A comp ehensi e sea ch o se e al da abases om da abase
incep ion o No embe 2013, only in English language, was
conduc ed. The da abases included Pubmed and ISI Web o
Science. The sea ch e ms «dehyd a ion» / “hypona emia”
/ “hype na emia” AND «cos » AND «elde ly» we e used
o sea ch o compa a i e s udies o he economic bu den o
dehyd a ion.
S udy selec ion
We conside ed all he empi ical s udies published in English
language ha e alua ed he e ec o dehyd a ion on hospi al
ou comes o elde ly pa ien s diagnosed wi h dehyd a ion.
S udies we e eligible i hei coho o pa ien s had a mean
age>60 and i hey epo ed medical ou comes o he han
mo ali y. They we e e iewed and a ed based on hei
ele ance o cos o illness and he eliabili y o he es ima es.
Ini ial abs ac sc eening excluded non- ele an s udies o
non-o iginal s udies. Full- ex sc eening was hen pe o med
o assess eligibili y. The o al numbe o a icles e ie ed was
126. A e a il e ing p ocess based on he ex o he abs ac ,
we kep 15 s udies. S udy cha ac e is ics and epo ed ou comes
a e desc ibed in Table 1.
Fu he mo e dep ession and loneliness usually obse ed in
elde ly pa ien s ha e been iden i ied as majo con ibu o s o
inadequa e luid in ake in hospi al and nu sing elde ly esiden s.
Te m dep ession e lec s symp oms such as sadness, lack o
mo i a ion, social isola ion, and hopelessness (6).
DEHYDRATION IN THE ELDERLY: A REVIEW FOCUSED
ON ECONOMIC BURDEN
M. FRANGESKOU1, B. LOPEZ-VALCARCEL2, L. SERRA-MAJEM1,3
1. Resea ch Ins i u e o Biomedical and Heal h Sciencies, Uni e si y o Las Palmas de G an Cana ia, Las Palmas de G an Cana ia, Spain; 2. Depa men o Quan i a i e Me hods in
Economics and Managemen , Uni e si y o Las Palmas de G an Cana ia, Las Palmas de G an Cana ia, Spain; 3. CIBERobn (Cen o de In es igación Biomédica en Red Fisiopa ología de
la Obesidad y Nu ición), Ins i u e o Heal h Ca los III, Mad id, Spain. Co esponding au ho : D . Lluis Se a Majem, Resea ch Ins i u e o Biomedical and Heal h Sciencies, Uni e si y o
Las Palmas de G an Cana ia, PO Box 550; 35080-Las Palmas de G an Cana ia, Spain. Telephone:+34 928 453476 Fax:+34 928 453475 E-mail add ess: [email p o ec ed]
Abs ac : Backg ound: Dehyd a ion is he mos common luid and elec oly e p oblem among elde ly pa ien s.
I is epo ed o be widely p e alen and cos ly o indi iduals and o he heal h ca e sys em. The pu pose o
his e iew is o summa ize he li e a u e on he economic bu den o dehyd a ion in he elde ly. Me hod: A
comp ehensi e sea ch o se e al da abases om da abase incep ion o No embe 2013, only in English language,
was conduc ed. The da abases included Pubmed and ISI Web o Science. The sea ch e ms «dehyd a ion» /
“hypona emia” / “hype na emia” AND «cos » AND «elde ly» we e used o sea ch o compa a i e s udies o
he economic bu den o dehyd a ion. A o al o 15 pape s we e iden i ied. Resul s: Dehyd a ion in he elde ly
is an independen ac o o highe heal h ca e expendi u es. I is di ec ly associa ed wi h an inc ease in hospi al
mo ali y, as well as wi h an inc ease in he u iliza ion o ICU, sho and long e m ca e acili ies, eadmission
a es and hospi al esou ces, especially among hose wi h mode a e o se e e hypona emia. Conclusions:
Dehyd a ion ep esen s a po en ial a ge o in e en ion o educe heal hca e expendi u es and imp o e pa ien s’
quali y o li e.
Key wo ds: Dehyd a ion, economic cos s, hospi alized pa ien s, elde ly.
J Nu Heal h Aging
Volume 19, Numbe 6, 2015
Recei ed Ap il 28, 2014
Accep ed o publica ion July 3, 2014
Dehyd a ion as a medical p oblem
Dehyd a ion in clinical p ac ice, and especially long
e m ca e, is mos o en unc ionally conside ed as a loss
o o al body wa e con en due o pa hologic luid losses,
diminished luid in ake o a combina ion o bo h (7). Howe e
i is impo an o unde s and and dis inguish he body’s h ee
o ms o wa e deple ion; hype onic, iso onic and hypo onic
(di e en se um sodium le els) (8) in o de o add ess and
unde line he causes in a imely and app op ia e manne .
Many s udies looking a he clinical ou comes o dehyd a ion
ha e shown ha dec eased luid in ake has a di ec impac
on indi iduals’ heal h s a us. Dehyd a ion has been p o ed o
be a majo isk ac o in he de elopmen o many diseases
such as s one disease (9, 10) o i appea s as a como bid
condi ion o mul iple diseases such as mi al al e p olapse and
sali a y dys unc ion (11, 12) ce ain ypes o cance s (12–14),
pulmona y diseases (15), hea ailu e (16), physical impai men
(17–21) con ibu ing o hei de e io a ion (22)
Dehyd a ion is no only widesp ead among he elde ly, bu
also an independen p edic o o mo ali y. A numbe o s udies
ha e epo ed mo ali y a es associa ed wi h hype na emia
g ea e han 40% (23–25) and a e commonly ela ed o he
unde lying disease p ocesses (24, 25). In a coho o 4123
elde ly pa ien s, Te zian e al (26) s udied he ela ionship
be ween hypona emia a he ime o hospi al admission and
ea men ou comes. A e con olling o di e en con ounde s
hypona emia was a signi ican independen p edic o o
mo ali y. In mo e ecen s udies such as he one by Wald e
al. (27) pa ien s diagnosed wi h hypona emia (<135 mmo/L)
had a isk o in-hospi al mo ali y as high as 47%, and ha isk
was doubled o pa ien s wi h a se um sodium concen a ion
be ween 125 and 129 mmo/L.
Inc easing age is a s ong independen isk ac o o bo h
hypo- and hype na emia (28). The concep o p og essi e
in e mi en ail y almos ensu es ha he elde ly will go
h ough pe iods o illness wi h associa ed dehyd a ion (29). The
easons o elde ly being exposed o highe isk o dehyd a ion
a e well known and documen ed in he li e a u e.
Fi s ly wa e and sal homeos asis a e a ec ed by a a ie y
o age ela ed ac o s (30, 31). As one ages, he e is less o al
body wa e due o a dec ease in lean body mass and an inc ease
in pe cen age o body a (32, 33). Mo eo e kidneys o elde ly
people p esen s uc u al as well unc ional changes (34,35)
leading o he de elopmen o hypona emia. Hypona emia
in u n inc eases he isk o o he illnesses (e.g. diso ien a ion,
coma e c.) (36).
In addi ion hi s sensa ion is lessened wi h age (32).
Findings consis en ly suppo he conclusion ha he elde ly
do no eel as hi s y as younge pe sons ollowing wa e
dep i a ion and subsequen ly do no d ink enough o ehyd a e
hemsel es (7, 37). Many elde ly may also in en ionally educe
hei luid in ake o educe incon inence, which has been ound
as a isk ac o o signi ican ly lowe luid in ake o a oiding
humilia ion (38, 39).
Figu e 1
Economic Bu den o Dehyd a ion
1. Inc ease/ 2. Leng h o S ay/ 3. In ensi e Ca e Uni / 4. Mechanical Ven ila ion/ 5. Long
Te m Ca e/ 6. Sho Te m Ca e
Dehyd a ion in he elde ly
Ano he ac o ha con ibu es o he p e alence o
dehyd a ion in elde ly people is hei highe a e o ch onic
illness (2) which can dis up he body’s abili y o balance and
manage luids and elec oly es (40, 41). Fo example pe sons
wi h diabe es (42) o neu ological and neu osu gical diseases
a e (8, 43, 44), cogni i ely impai men (40) a e pa icula ly a
isk o dehyd a ion. Howe e he ela ionship o deli ium and
dehyd a ion is complex, because each may con ibu e o he
o he in a icious cycle. Some elde ly people simply do no
know how much luid hey need o do no emembe o ask o
i because hey a e cogni i ely impai ed (40) bu dehyd a ion
can i sel con ibu e o impai ed men al unc ion, which may
hen make he su e e o ge o d ink, and so on (8).
Mo eo e , mul iple diseases such as ca diac glycosides
(45), u osemide (24), laxa i es (46), and dila ing supp esses
asop essin elease (32) usually ound in elde ly a e combined
wi h in ensi e d ug consump ion which no su p isingly has
un owa d side e ec s on wa e and elec oly e balances o
indi iduals. Addi ionally dehyd a ion has also been associa ed
wi h malnu i ion (47), esul ing in educ ion o seconda y hi s
as ood consump ion declines. Ano he hypo hesis sugges s
ha aging is associa ed wi h changes in sa ia ion ha hinde
adequa e ehyd a ion in esponse o hype osmola i y (48) and
swallowing di icul y (6).
Finally dep ession and loneliness usually obse ed in
elde ly pa ien s (especially in nu sing home pa ien s) ha e been
iden i ied as majo con ibu o s o inadequa e luid in ake in
DEHYDRATION IN THE ELDERLY: A REVIEW FOCUSED ON ECONOMIC BURDEN
J Nu Heal h Aging
Volume 19, Numbe 6, 2015
620
JNHA: NUTRITION
J Nu Heal h Aging
Volume 19, Numbe 6, 2015
621
Table 1
Cha ac e is ics o he Eligible S udies
Re . No. Fi s Au ho , Numbe o Inclusion De ini ion o P e alence Mean Age Yea s o Single (S)/ Se ing Da a sou ce Clinical ou comes
Yea pa ien s (n) c i e ia dehyd a ion o dehy- (yea s) pa ien Mul icen e Mo ali y LOS (days) Readmission Admi ed A e age cos s
(Coun y) d a a ion coho (M) a es (%) o ICU (%) pe pa ien
(%)
37 Wa en e al, 731.695 All Medica e bene- ICD-9-CM: 276.5 65=< 1991 M Hospi al MEDPAR 17.4% (in 30 2,942 ($) o
 1994(US)  icia iespa ien s        days);30.6%    cases
   hospi alizedolde         (in31-360days)    wi hp incipal
   han64yea s            diagnosiso  
               dehyd a a ion
62 Mukand e 39 P ospec i e pilo p e enal azo emia: 53,80% 78 2004- S Hospi al HD 12.9 s 9.4
 al,2003  s udywi h  BUN/C ea ine      2005
O hopedic Pa ien s a io>=20
     o hos a ichypo-  46,20%             13.7 s9.8
     ension:SBP*>=15              
49 Hong e al, 31.077 Hospi aliza ion ICD-9-CM: 276.5 80,4 1999 M Hospi al HCUP 7442 ($) Pe
 2004(US)  episodespa ien s            NIS         day:1628($)
   >=65yea s
p incipal diagnosis
   o dehyd a ion;
discha ged ali e
68 Gheo ghiade 48.612 Pa ien shospi a- SSL<135mmol/L 19,70%  74,1  2003-  M  Hospi al (OPTI 6.0 s3.2 6.4 s5.5
 e al,2007(US) lizedwi hhea         2004     MIZE-
ailu e (CHF) HF)
52 Sheae al, 167.299 Allhospi alized Hypona emia:  0,80%  64  1999-  M  Hospi alIHCIS       Annualmedi-
 2008(US)  pa ien s(anyage) (SSL<135      2005             calcos s:
     mmol/L)                   19215($) s 
     Hype na emia  1,90%  59               9257($)/
     (SSV>145mmol/L)                  Annualinpa 
ien cos s:
10636($) s
468($)
Annual medi
cal cos s:
10972($) s
                         9257($)/ 
Annual inpa
ien cos s:
4734($) s
3468($)
2 Wake ielde  96cases, Casecon ols udy. ICD-9-CM: 0.55%  65  1995-  S  Hospi alHD ns
 al,2008 93con ols Casesa emale 276.0,276. (Hypona    2000 
 (F ance)  pa ien swi hone 1,276.5 emia
o he h ee selec ed accoun ed
ICD-9 codes. o 18.8%
   Ma chedbyage,   o dehy
   wa dloca ion   d a ed
and admission pa ien s)
   mon h(wi hin
   hesameyea )      
63 Zilbe be ge  198.281 Allpa ien shospi a Hypona emia 5,50%  65,7  2004-  M  Hospi al Solucien ’s 5.9 s.3.0 8.6 s.7.2  17.3 s.  16502 s
 al,2008  lized(anyage). SSL<135      2005      ACT acke       10.9  13558($)
 (US)a  Objec i e: o mmol/L
es ima e he p e a
   lenceo hypona
emia and he
   in luenceo 
   admissionhypo
na emia on hospi
al cos s and ou
DEHYDRATION IN THE ELDERLY: A REVIEW FOCUSED ON ECONOMIC BURDEN
J Nu Heal h Aging
Volume 19, Numbe 6, 2015
622
comes
62 Zilbe be g e 7.965 Pa ien s admi ed SSL<135 8,20% 72,4 2004- M Hospi al Solucien ’s 7.6 VS 7.0 10 VS 6.3 7,086 VS
al, 2008 wi h Pneumonia mmol/L & 2005 ACT acke 5,732 ($)
(US)b ICD-9-CM:
276.5
71 Callahan e 10.120 Re ospec i e SSL<129 20,20% - 2004- M Hospi al HD 8 s 6 32 s 26 16,606 ($)
al, 2009 coho s udy all mmol/L 2005
(US) s 13,066($)
adul admissons SSL<130- 9 s 6
26 s 22 14,266($) s (any age) 134 mmol/L
13,066($)
27 Wald e al, 53.236 Coho s udy. SSL<135 Communi y-. 66,7 2000- S Hospi al HD 3.4 s 2.0 5.9 s 5.2
2010 (US) All adul hospi a mmol/L acqui ed 2007
liza ions in hypona emia:
which se um 37.9%
Sodium concen Hospi al 69 yea s 2.9 s 1.4 7.6 s 4.9
a ion a admis acqui ed
sion was eco ded hypona e
we e included. I mia: 38.2%
compa es
Communi y
aqui ed hypona
emian wi he
hospi al acqui ed
hypona emia
67 Sho e 115.969 Pa ien s hosp Se e e hypona 5,30% 75,4 2004- M Hospi al Ca e 7.6 s 2.9 6.9 s 5.4 11,109($) s
al, 2011 i alized wi h emia: SSL<130 2005 Fusion 9,192($)
(US) conges i e hea mmol/L
ailu e (CHF) Hypona emia: 15,90% 74,3 4.9 s 2.9 6.1 s 5.4 10,033($)
SSL<131-135 s 9,192($)
mmol/L
Hype na emia: 3,20% 76,9 6.7 s 2.9 6.0 s 5.4 9,418($)
SSL>145 mmol/L s 9,192($)
58 Amin e 558,815 Re ospec i e s udy ICD-9-CM: 276.1 70 2007- M Hospi al P emie 8.8 s 8.5 17.5 s 16.4 15,281 ($)
al, 2012 cases and pa ien s hospi alized, 2010 HD s 13,439 ($)
(US) 558,815 any age. Case con ol
con ols s udy. Compa isons
o hospi alized
hypona emic (HN),
p ima y o
seconda y e sus
non-HN pa ien s
60 Amin e 25,855 Pa ien s hospi alized ICD-9-CM: 276.2 75,36 2007- M Hospi al P emie 7.7 s 6.3 21.4 s 5.0 13,339 s
al, 2013 cases and wi h hea ailu e 2011 HD 10,475 ($).
(US) 25,855 any age. Case con ol ICU
con ols s udy. Cases a e Cos s= 7,195
hypona enic pa ien s, $ s 5,618$
con ols a e non hy
pona enic pa ien s
69 Rabino 635 Pulmona SSL<135 mmol/L 22,40% 66 2006- S Hospi al HD O e all: 7.4 VS 6.3
i z e al, Hype ension 2008 27% /
2013 (US) HR=1.82
59 Tu gu alp 253 All elde ly pa ien s SSL<135 mmol/L 4,1% 65=< 2010 S ED HD 31,3 9,56 58.6 Me 1,524.4 ($)
e al, 2013 admi ed in he ED (65-74 dical
(Tu key) depa men om 2010 yea s); suppo
we e e alua ed. I 7.8% needed in
compa es wo g oups (75 yea s 19.3%
o pa ien s, 65-75 and olde ) 51,4 11,8 76.9 Me 1,745.7 ($)
yea s and 75 and olde dical suppo
needed 35.9%
*HCUP=Heal hca e Cos and U iliza ion P ojec (HCUP) Na ional Inpa ien Sample; *IHCIS=In eg a ed Heal hCa e In o ma ion Se ices (IHCIS) Na ional Managed Ca e Benchma k Da abase; *HD=HD (Hospi al Da abase); *ME-
DPAR=*Medica e P o ide Analysis and Re iew (MEDPAR); *OPTIMIZE-HF egis y=*O ganized P og am o Ini ia e Li esa ing T ea men in Hospi alized Pa ien s wi h Hea Failu e (OPTIMIZE-HF) egis y; *SSL=Se um Sodium
Le el;*Whene e ageo pa ien swas epo ed o di e en g oupsweonly epo ed heageo pa ien g oupdiagnosedwi hdehyd a ion;*ICD=In e na ionalS a is icalClassi ica iono Diseases;
hospi al and nu sing elde ly esiden s. Te m dep ession e lec s
symp oms such as sadness, lack o mo i a ion, social isola ion,
and hopelessness (8).
P e alence o Dehyd a ion among elde ly
The e idence o dehyd a ion among he elde ly is well
known and documen ed (49, 50). Dehyd a ion a ec s a la ge
numbe o elde ly pe sons (51) and cases can only be expec ed
o inc ease as he elde ly come o make up an e en la ge
segmen o he popula ion. Ha eman-Nies e al (51) s udied he
luid in ake o elde ly Eu opeans and ound ha luid in ake o
elde ly people a ied be ween he owns o Eu ope and be ween
men and women. A high pe cen age o he emale popula ion
had a wa e in ake below he cu -o alue. Pa ien s diagnosed
wi h hypona emia we e mo e likely o be emale in mos o he
s udies (49, 52, 53).
Inc easing age was a majo ac o in isk o admission wi h
dehyd a ion in mos o he s udies. Fo example Hong e al (49)
using hospi al discha ge da a om he Heal h Ca e Cos and
U iliza ion P ojec (HCUP), ound ha mo e han hal o he
hospi aliza ions in ol ing a p incipal diagnosis o dehyd a ion
we e o indi iduals o a leas 65 yea s o age. Wa en e al
(37) epo ed ha pa ien s 85 o 99 yea s o age we e 6 imes
mo e likely o be hospi alized o dehyd a ion han hose
65 o 69 yea s o age. Simila ly Cu ze e al (54) ound ha
hospi aliza ion- equi ed hypona emia is mo e common in e y
elde ly pe sons han in elde ly (Table 1).
Fu he mo e hypona emia has been epo ed o be almos
20% in olde adul s p esen ing o he eme gency depa men
(ED) (55) and i has also been obse ed in many hospi al
admissions o nu sing home esiden s (8). Few olde s udies
a ailable on he p e alence o dehyd a ion among he elde ly
sugges ed ha hose li ing in LTC acili ies we e wice as
likely o be dehyd a ed (22%) as he acu ely ill hospi alized
elde ly (11%)(56). Mo e ecen s udies con i m hese indings.
Men es e al (57) ound ha dehyd a ion e en s occu ed in
31% o esiden s o e 6 mon hs and in wo o he s udies, 34%
o nu sing home pa ien s admi ed o hospi al we e diagnosed
wi h dehyd a ion (39) and 84% o hype na aemic pa ien s
de eloped his du ing admission o hospi al while 16% we e
hype na aemic on admission (23).
Economic Consequences
Enume a ion o e ec s
Al hough he clinical consequences o dehyd a ion in
elde ly a e well documen ed, ela i ely li le is known
abou he ela ionship be ween dehyd a ion and medical
cos s. Hypona emia among hospi alized and communi y
elde ly pa ien s ca ies impo an clinical and economic
implica ions. Whe he i is p esen on admission, exace ba ed
a e admission, o de elops du ing hospi aliza ion, i
impa s a conside able bu den on he consump ion o
heal hca e esou ces (52, 58). I con ibu es o an inc ease
in hospi aliza ions (37, 49), admission o ICU (27, 58–60),
eadmission o he hospi al (58) and disposi ions o long e m
o sho e m ca e acili ies (27, 61). I is e iden ha all hese
ac o s inc ease hospi al cos s h ough he inc ease in usage o
hospi al equipmen , d ugs, medical es s and p ocedu es (59,
62, 63), need o hospi al s a ; doc o s, nu ses e c.
Cos ypes o be conside ed, sou ces and measu es (di ec
and indi ec cos s)
Dehyd a ion subs an ially inc eases he heal h
ca e bu den in a di ec way, as a disease i sel , o an
indi ec way as como bidi y o ano he disease. Fo
example hospi aliza ions o dehyd a ion can be assumed
o be a di ec p edic o o heal hca e cos s. The numbe o
hospi aliza ions o dehyd a ion has s eadily inc eased in
ecen decades. Speci ically o e he decade o 1990-2000
he a e o dehyd a ion ela ed hospi aliza ions in he US
inc eased by 40.4% (64). Many s udies epo ed high a es o
hospi aliza ions o dehyd a ion among he elde ly popula ion
(37, 49). Fo example Wa en e al (37) epo ed ha he a e o
hospi aliza ions pe 10 000 elde ly was 236.2 admissions wi h
any lis ed diagnosis o dehyd a ion and 49.7 admissions o
dehyd a ion as he p incipal diagnosis.
Addi ionally dehyd a ion leads o he de elopmen o o he
diseases, which lead o hospi aliza ions and a e di ec ly ela ed
o an inc ease o heal hca e cos s. Indeed Zilbe be g e al (63)
ound ha hypona emic pa ien s ha e a highe co-mo bidi y
index han pa ien s wi h no mal se um sodium. The e is no
doub ha hese co-mo bidi ies con ibu e o he need o
eme gency depa men s and an inc ease in leng h o s ay (LOS)
(59).
Al hough dehyd a ion is a disease i sel i is also appea ed
as como bidi y condi ion in a numbe o diseases. Acco ding
o an AHRQ s udy o he 1997 Na ionwide Inpa ien Sample
(NIS) (65) ep esen ing all pa ien s in acu e ca e hospi als,
dehyd a ion was diagnosed mo e commonly as como bidi y
han as a p incipal diagnosis. Dehyd a ion was he second
mos common como bidi y, occu ing in 14% o all
hospi aliza ions (64). Thus, dehyd a ion may con ibu e o
he inc ease o medical cos s in an indi ec way. I may be
a ma ke o he se e i y o he unde lying disease o i may
add i s own complica ions o hose o he unde lying diso de
(63). Fo ins ance Chine al, pe o med a e ospec i e s udy
o 435 pa ien s admi ed o a uni e si y hospi al pe o ming a
mul i a ia e analysis o hese pa ien s and ound ha he se um
[Na+] < 135 mmo/l was a signi ican and independen p edic o
(p<0.01) o majo complica ions in a pa ien ’s heal h s a us (66)
The e is a wide ange o s udies in he li e a u e analyzing
and epo ing he e ec o dehyd a ion as a como bidi y
disease on he clinical and medical ou comes o di e en
elde ly pa ien such as o hopedic (61), wi h hea ailu e (60,
67, 68), pulmona y diseases (62, 69) and many o he s. Fo
example Mukand e al, (61)and Zilbe be g e al (62) in hei
s udies ound ha dehyd a ion p olongs leng h o s ay o
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pa ien s admi ed wi h o hopedic and pneumonia espec i ely.
Addi ionally Rabino i z e al (69) ound ha hypona emic
pa ien s had longe leng h o s ay bu also highe a e o
hospi al eadmission.
In addi ion dehyd a ion causes luid de ici s wi hin cells
which can a ec he abso p ion o medica ions and a e s
d ugs’ expec ed e ec s. The e o e comp omises op imal
ea men o he unde lying diso de (4) causing p olonga ion o
ea men e ec s. Ch onic disease and diso de s, and mul id ug
he apy ela ed o hese condi ions a e common in elde ly
pe sons (70). Salmon (18) in his s udy poin ed ou ha pa ien s
wi h dehyd a ion ha e mo e di icul ies in abso bing he
medica ion o some diseases hey ace leading o a e a da ion
o hei healing.
Dehyd a ion hus ac s as an independen ac o in he
inc ease o he du a ion o hospi aliza ion (27, 52, 58, 60–63,
66, 68, 69, 71); hospi al eadmission a e (58 ,60), he need o
in ensi e ca e (27, 58-60): use o medical suppo (52, 59) and
he disposi ion o long o sho e m acili y (27, 61). This is
simply because dehyd a ed pa ien s ep esen a sicke coho
among all hose wi h he unde lying diso de . These ypes o
cos s can be assumed as di ec cos s incu ed by dehyd a ion
(Figu e 1).
Howe e he e is no doub ha he indi ec cos s o
hypona emia such as ime and p oduc i i y loss by pa ien s
and ca egi e s because o he illness as well as income los
by pa ien s and amily membe s, pose a subs an ial bu den on
households (Figu e 1). Howe e , as a as we know, no s udy
has been conduc ed es ima ing hese ypes o cos s.
O e iew o he me hods o calcula ing cos s
The s udies ound in he li e a u e e lec he di e si y o
me hods used o assess he economic bu den om dehyd a ion
in he socie y. The me hodological di e ences in he s udies
inhe en ly p e en a o mal me a-analysis om being
pe o med. A discussion on he di e en me hodologies used
ollows:
Fi s ly he e is di e si ica ion among he s udies in he
de ini ion o dehyd a ion. Some s udies de ine hospi aliza ion
o dehyd a ion wi h he code ICD-9-CM o ICD-10-CM
(In e na ional Classi ica ion o Diseases, Nin h Re ision,
Clinical Modi ica ion) as eco ded in na ional da abase (2,
37, 49, 58, 60). Fo example Wake ield e al (2) in hei s udy
as a case hey de ined a pa ien wi h one o h ee ICD-9-CM
codes as he p incipal diagnosis (i.e., eason o admission).
The h ee p incipal diagnoses ICD-9-CM we e hype osmolali y
o hype na emia, hypo-osmolali y o hypona emia; and
olume deple ion (22). While in o he s udies, whe e da a
a e a ailable au ho s de ine dehyd a ion acco ding o he
se um sodium le el o he hospi alized pa ien s (27, 52, 59,
61–63, 67–69, 71) and e en mo e hey assessed he impac o
di e en le els o dehyd a ion on paien s’ ou come (52, 59,
67). Fo ins ance Tu gu alp e al (59) looked on he se e i y
o he disease. They sepa a ed hei pa ien s acco ding o hei
le el o hypona emia, depending on se um Na le el; mild
hypona emia (130 mmo/l < Na+ <135 mmo/l), mode a e
hypona emia (120 mmo/l < Na+ <130 mmo/l) and se e e
hypona emia (Na+ <120 mmo/l). Howe e , mos au ho s s udy
only he economic e ec s o hypona emia assuming ha i is
he mos common ype o dehyd a ion (58, 60). Addi ionally
he e a e some au ho s who used indices o dehyd a ion such as
BUN/C ea ine a io and sys olic blood p essu e (61).
Secondly he s udies di e in he ou comes o measu e.
Some s udies look only on hospi al admission cos s (37, 49) o
dehyd a ion while o he s look on hospi al (27, 58–63, 67–69,
71) o (ICU) leng h o s ay (LOS) (58, 60, 62) , in ensi e ca e
uni (ICU) cos s o admission (58, 60), hospi al eadmission
a es (58, 60) , admission o ICU (59, 61–63) , need o medical
suppo (MV) (59, 62, 63) as well as disposi ion o sho o long
e m ca e acili ies (27, 61); all o which a e d i e s o cos s.
Di e si y in he de ini ion o ou comes has also been
obse ed. Fo example some s udies look only on he cos o
hospi aliza ions wi h a p incipal diagnosis o dehyd a ion (37,
49). Da a limi a ions p e en hose s udies o look on he cos
o dehyd a ion as a como bidi y condi ion. Hong (49) and
Wa en e al (37) conse a i ely es ima e he economic bu den
associa ed wi h a oidable hospi aliza ions o dehyd a ion by
assuming equi alency be ween hospi al cha ges and cos s.
Whe eas au ho s, whe e da a allow hem, calcula e o al
medical cos s by summing he gi en s anda dized cos alues
o all hypona emic pa ien s ound in inpa ien acili ies,
ou pa ien acili ies, p o essional se ices, and ambula o y
se ices incu ed in hei s udy pe iod (52).
Thi dly s udies di e in hei g oup o pa ien s. A numbe
o s udies look on he impac o dehyd a ion as a p ima y o
seconda y diagnosis o hospi aliza ions (27, 37, 49, 52, 58, 63,
71) while o he s udies look on i s impac on a speci ic g oup
o pa ien s such as pa ien s wi h hea ailu e (60, 67, 68),
pulmona y diseases (62, 69) and o hopaedic (61).
Mo eo e s udies di e in hei se ing o s udy. Al hough in
many s udies he sample o s udy was comp ised om all he
pa ien s admi ed in he hospi al, some au ho s s udy a speci ic
g oup o hospi alized pa ien s (e.g. Eme gency depa men ,
ICU e c). Tu gu alp e al (59) o example es ima ed he
clinical ea u es, ou comes and cos s o pa ien s admi ed o
he eme gency depa men (ED) and we e iden i ied wi h
hypona emia . While Mukand e al (61) looked only on
pa ien s who ook su ge y, he e o e on su gical depa men .
I also wo h men ioning ha a numbe o s udies look on
only on pa ien s admi ed o a single cen e (2, 27, 59, 61, 69)
while o he s udies which mainly use da a om da abases wi h
a sample o hospi als, mul icen e (37, 49, 52, 58, 60, 62, 63,
67, 68, 71). A ac o ha di ec ly a ec ed hei indings.
Finally he s udies di e in hei design and s a is ical
analysis. Economic e alua ions o dehyd a ion ha e been
done in di e en ways by di e en esea che s; mos o
hem pe o med e ospec i e s udies using al eady collec ed
longi udinal e ospec i e da a o elde ly pa ien s hospi alized
DEHYDRATION IN THE ELDERLY: A REVIEW FOCUSED ON ECONOMIC BURDEN
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in di e en academic and non-academic hospi als (2, 27, 37,
49, 52, 58–60, 62, 63, 67–69, 71). In con as Mukand e al (61)
pe o med a p ospec i e, pilo s udy, whe e he subjec s we e
pa ien s who had su ge y o o hopaedic easonsAl hough he
me hodologies and hence he nume ical esul s o hese s udies
a y, all o hem send a message o he p ope managemen o
he hyd a ion s a us o pa ien s, ea ly de ec ion and p e en ion
so as o a oid an unnecessa y inc ease in medical cos s.
Re iew o he e idence on he economic bu den o
dehyd a ion in elde ly people
All o he s udies e iewed assessed di ec cos s o
dehyd a ion disease, which include all he cos s incu ed by
hospi alized pa ien s. The nume ical esul s o hose s udies
a y because o he di e ences be ween he s udies, men ioned
abo e. In his sec ion we p esen e idence on hese di ec cos s.
Wa en e al (37) ound ou ha dehyd a ion was 1 o 10
mos equen diagnoses epo ed o hospi aliza ions o pe sons
o e 65 and accoun ed o Medica e eimbu semen o hospi als
in excess o $446 million o a single yea . Zilbe be g e al (63)
es ima ed $2289 o $3480 ise in o al hospi al cos s o each
day o each pa ien hospi alized wi h hypona emia. Howe e ,
Shea e al (52) ound ha 1-y mean inpa ien cos s o pa ien s
wi h hypona emia we e app oxima ely $10,636, mo e han 3
imes highe han he p e ious es ima e o Zilbe be g e al (63).
In hei s udy, inpa ien cos s accoun ed o jus o e hal o all
di ec medical cos s.
In addi ion in hei compa ison o he hospi al cos s be ween
hypona emic and non-hypona emic pa ien s mos o he
au ho s ound signi ican di e ences (58–60, 62, 63, 71).
Fo example Callahan e al (71) ound ha pa ien s wi h
hypona emia cos 14266$ pe admission compa ed o he non-
hypona emic pa ien s which cos 13066. Simila ly Zilbe be g
e al (63) ound almos 3000$ di e ence be ween he wo
g oups.
Fu he mo e, inc eases in leng h o s ay (LOS) due o he
nega i e e ec s o hypona emia on he heal h o pa ien s ha e
been shown by a numbe o au ho s (27, 52, 58, 60–63, 66,
68, 69, 71). The di e ence in hospi al LOS a i s admission
be ween HN and non-HN pa ien s in he s udy Amin e al (58)
was 1.1 days. Simila o ha epo ed in a s udy conduc ed by
Sho e al (67) which ound a 0.7 and 1.28 day g ea e LOS
o HN and se e e HN HF pa ien s, espec i ely, in compa ison
wi h non hypona emic HF pa ien s]. Zilbe be g (63) and
Callahan e al (71) pe o ming e ospec i e coho analyses
and making he same compa ison epo ed a di e ence o 1.4
days and 2.0 days espec i ely.
Pa ien s diagnosed wi h hypona emia a e signi ican ly mo e
likely o be eadmi ed o hospi al o any cause han pa ien s
wi h simila demog aphics and cha ac e is ics who do no ha e
hypona emia (58, 60). Hospi al eadmissions a e a signi ican
con ibu o o o al heal hca e cos s, wi h some being en i ely
a oidable wi h inc eased s anda ds o ca e. Gheo gheade e
al (68) in hei s udies which we e conduc ed on clinical ial
pa ien s wi h acu e hea ailu e ound ha HN pa ien s in
compa ison o non-HN pa ien s epo ed a signi ican inc ease
in eadmission a es. Howe e , Amin e al (60) epo ed ha
hypona emia was associa ed wi h an inc emen al inc ease
anging be ween 14% and 17% o hospi al eadmission o any
cause.
Zilbe be g (63) and Callahan e al (71) epo ed ha HN
pa ien s had a signi ican ly g ea e need o ICU (4%–10%).
Hypona emia is a e y ele an elec oly e diso de among
people who epo o he eme gency depa men (ED). Focusing
on ICU popula ion Zilbe be g e al (63) ound ou ha
hypona emia was wice as equen as in he o e all hospi al
popula ion (11.3%) and i s independen associa ion o wo sened
ou comes pe sis ed. Fo example, hypona emic ICU pa ien s
we e signi ican ly mo e likely o expe ience such di e clinical
ou come as hospi al dea h, as well as o equi e mechanical
en ila ion. Wi h an a e age adjus ed cos o MV o $1,500 pe
day, his inc eased u iliza ion is likely o add subs an ially o
he o e all cos s o ca e. Simila ly Tu gu alp e al (59) in hei
s udy epo ed posi i e ela ionship be ween he age and he
need o in ensi e ca e and en ila o suppo . Amin e al (58)
in hei sudy es ima ed ICU cos s pe admission and ound ha
hypona emic pa ien s cos s app oxima ely 1600$ mo e han
non-hypona emic pa ien s.
Se e i y o hypona emia p ognos ica es ad e se ou comes,
especially when hypona emia de elops in hospi al. Acco ding
o Wald e al (27) pa ien s wi h hospi al acqui ed hypona emia
ha e highe isk o dea h compa ed o he communi y acqui ed
hypona emia. Mo eo e pa ien s wi h hospi al acqui ed
hypona emia we e shown o be equen ly associa ed wi h
delays in he imi a ion o ea men .
A agg ega e le el, he po en ial na ional sa ing om
a oidable hospi aliza ions in elde ly pa ien s (olde han 65)
hospi alized o dehyd a a ion has been es ima ed in $1,14
billion o 1999 (49).
Final conside a ions
This li e a u e e iew has p esen ed he a ailable e idence
on he economic bu den ela ed o dehyd a ion. Howe e
be o e concluding i s mos impo an esul s, some o he
me hodological issues in many o he s udies ha we e included
will be highligh ed. Fi s , in mos e ospec i e coho s udies
he p e alence o hypona emia illness was based in la ge pa
on he numbe o hospi aliza ions wi h he code ICD-9-CM o
ICD-10-CM as eco ded in a na ional da abase (49, 58, 60, 62,
63, 72). The e was e idence ha hese codes o hypona emia
ep esen only a low p opo ion o he pa ien s admi ed o
he hospi al and we e expe iencing hypona emia, due o he
low sensi i i y o he diagnosis code (73). Mo eo e , a high
p opo ion o hypona emia in he hospi al se ing is ia ogenic
and hospi als may be eluc an o include he code in he
discha ge da a. Any e ospec i e analysis may ha e hus aced
he same s udy limi a ions (73).
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Volume 19, Numbe 6, 2015
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Second, he s udies which used indi idual como bidi y
indexes mainly used adminis a i e codes. This is ela i ely
c ude and does no accoun o he se e i y o he condi ion
in ques ion. The e o e he inabili y o inco po a e he se e i y
o he como bidi ies migh ha e led o some unmeasu ed
con ounding in he analysis. The subs an ial a ia ions in
s udy designs and de ini ions desc ibed ea lie also make
compa isons icky and me a-analysis in easible. The e is
conside able he e ogenei y in me hodologies used in he pape s.
Taking in o conside a ion he me hodological issues
highligh ed he e we can s ill conclude ha dehyd a ion
al eady imposes subs an ial inancial cos s in he socie y.
Acco ding o he deg ee o magni ude o he dehyd a ion in
hospi alized pa ien s inc ease cos s by 7% o 8.5%. Highe
cos will be associa ed wi h an inc ease in hospi al mo ali y,
as well as wi h an inc ease in he u iliza ion o ICU, sho
and long e m ca e acili ies, eadmission a es and hospi al
esou ces, especially among hose wi h mode a e o se e e
hypona emia. The mo e se e e he le el o hypona emia,
he mo e likely a pa ien ’s hospi aliza ion will be p olonged
(27, 71). Da a a ailable om bo h he US (74) and Eu ope
(75) show ha mo ali y and medical cos s a e educed by
e ec i e ea men o hypona emia (58, 60, 62, 63, 67, 68).
Howe e , mos o he esea ch is only based on di ec s cos s
o dehyd a ion. The e o e u u e esea ch needs o be done in
es ima ing indi ec cos s associa ed wi h i in o de o ha e a
mo e comple e pic u e o i s economic bu den.
Dehyd a ion as a synd ome canno be ea ed me ely by
h owing wa e a i ! Su eys should look no a i s me e
sen inel p esence, bu whe he i was add essed in a mul i-
ace ed me hod ha accoun s o unde lying cause(s), conside s
pha macology in ol ed, e iews he in ol emen o he
physician and s a , add esses mo al p inciples ha a ise, and
places i in he con ex o indi idual ci cums ances. We need
a be e eali y in long e m ca e ha add esses educa ion
ega ding mode n hough s abou dehyd a ion, he impo ance
o ca e ul clinical app oaches, he concep o una oidabili y,
and he need o econside how we su ey his complex en i y.
Pa ien s’ admission and discha ge s a is ics should accu a ely
include he diagnosis o dehyd a ion as a como bidi y o main
disease, in o de o help o pa ien managemen and o allow
app op ia e esea ch and compa isons ac oss cen es.
Rapid ecogni ion and op imal ea men o dep essed se um
sodium o osmo ali y can educe he isk o dea h and symp om
se e i y, pe mi less in ensi e ca e, educe he du a ion o
hospi aliza ion and associa ed cos s, inc ease success in
ea men o unde lying como bid condi ions, and imp o e
quali y o li e. This implies a heal hie and au oma ically
mo e p oduc i e popula ion. In hei s udies Lica a (76)
and Leadbe e e al (77) ha e shown ha ea men o
hypona emia and dehyd a ion educes he equency and
se e i y o many side e ec s. These bene i s elie e pa ien s
om men al and economic cos s, inc easing hei quali y o li e.
Con lic o in e es s: This e iew was suppo ed h ough a esea ch g an om he
Eu opean Hyd a ion Ins i u e (EHI) alloca ed o he Fundación Uni e si a ia de Las
Palmas. None o he au ho s decla e any con lic o in e es . D . Se a-Majem se es as
a membe o he Scien i ic Commi ee o he EHI bu did no pa icipa e in he p ocess o
esea ch g an selec ion and alloca ion. The au ho s acknowledge he suppo om he EHI.
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