It Might Just Be Dehydration

(soft music) - Welcome to SNIFTIS, the podcast where we pull back the bedsheets on skilled nursing facilities, educating, entertaining, and occasionally risking being reported to HR. - Welcome to this episode of SNIFTIS, very, very excited to have now my friend, hopefully Dr. Hammrich, who also does a lot of work for vital care and terms of like supervising. And hopefully even more work in training. So very excited to have you on our podcast. - Thank you so much for this opportunity. - And a fellow German. - That's right. - So very excited. - And though my accent, I'm from the East Bond, Germany, my, one of my sons lives in Munich, and I get to see my grandchildren in a few weeks. - And we're very excited. How many grandkids do you have? - I have four grand sons. - Four grand, sons. - Yeah, no granddaughters. - No girl among the whole family. - Yeah. - And they tend to take care of us when we get older. - Yeah. - So. - Well, hopefully the dice world was good. (laughing) We're gonna talk a lot about, it's like dehydration and hydration and kind of the impact that I have on multiple like body systems and disease course management. And a lot of the acute care calls that we get from skilled nursing facilities can be, I think tied back to dehydration. So really excited to talk about that too. - It really is the root cause of many of the illnesses that our patients face, especially acute illnesses. So I became very passionate about this topic and I'm really excited to teach you about this. - Perfect. So let's start with your background, your training, what got you into healthcare, specifically long-term care. And then I think one of the most important questions is, why do you stay? - Right. - It's a hard place to be, so why do you stay? - Yeah. So I wanted to be a physician since I was nine and when I entered medical school, I wanted to go into surgery. But all my patients were asleep, bent over the over table, got boring. So I was like, this is not for me. So then I did all the rotations and loved everything. So I went into family medicine, but when I was in family medicine, I was really excited about older patients. They were so appreciative of everything that I did for them. I loved the complexity because nothing ever got boring. You know, with pediatrics, you see 80% ear infections. Not very exciting. But with geriatrics, it's a different issue every time you see them and every patient you see. So that's what caught me into it. And that's why I'm staying, too, because I like the challenge and I like learning new things. So early in my career, I learned that dehydration is the main, the root cause of so many of my patients problems. So we'll talk a little bit about them. For example, when I would start an anti-apetensive for my patients for high blood pressure, oftentimes they would call me in a couple of days saying, "I'm dizzy," or "I would call them to see if they have any side effects from the medications." And they would say, "I'm dizzy." And I'm like, "Well, you know, it's just because you're not drinking enough because the vasodilation increases the capacitance." So all your blood volume goes to your lower extremities when you're standing up or sitting up. So if you don't drink enough, you're not perfusing your brain and you feel dizzy. So that's when I started recommending my patients double their fluid intake whenever I would start the monomotication for blood pressure or increase their dose. - Interesting. Plus a lot of them, in terms of anti-apetensives, can escalate to a diuretic or something. So you have a combination of polypharmacy that's impacting this. - So I'm going to bring them up with diuretic. Diuretic blood pressure medications are diuretics only for about a year, then after that they lose a diuretic effect and become only blood pressure medicines. And vasodilators, so not so much diuretics. (laughing) So if the patient has been on the hydrochlorozyze or the porhthaladone for several years, that's not going to be the cause of their dehydration. - It's about a acute change just in the recent. It's like more of a past. So I think dehydration as you look at it across the board. So we get a lot of acute calls for like hypotension that I think can be correctly managed by giving them fluids, but we're not figuring out the reason why necessarily die-hypertensive. But they could be dehydrated, but there could be other causes related to medication. Like some of their activity, like diuretics, but the other thing I get interesting sometimes is dehydration can also impact your heart rhythm. Isn't that correct? In terms of like AFib or like in and out of that. And how does that impact in terms of where we're at? - So dehydration can lead to hyperbolemia and then the kidney send out no epinephrine and epinephrine and that then raises the cataclysmines in the blood. And that has effects on the receptors of the heart, increasing the heart rate, but also increasing the risk of atrial fibrillation. Because the SA, you know, which is the pacemaker of our heart, it attributes much faster than the rest of ourselves in our body. Our skin cells, we are left with about 50% of our skin cells on age 80. The SA node cells, 90% are gone. So our heart is much more prone to develop atrial fibrillation and other arrhythmias when we get older. But to get back to the dehydration. So there are several reasons why older adults are at higher risk of dehydration. Due to apoptosis or program cell death, our brain cells that trigger thirst are atrophy and are gone. We don't feel so serious, even when we're older. Then we make less antidiuretic hormone in the brain when we're older, again, because of apoptosis. And with less antidiuretic hormone, we don't concentrate the urine as effectively and therefore lose more water in the urine when we're older. And that's why many older adults have to get up in the middle of the night. Because at night, we usually make a lot of antidiuretic hormones so we don't have to pee at night. But if we don't make as much, we have to get up in the middle of the night to go beach. So even if we made enough antidiuretic hormone in an older person, the kidney is not as responsive to it. Because the long left front that concentrate the urine most effectively have atrophy the earliest. So we have fewer left front, especially the long ones. So we don't concentrate the urine as effectively. And therefore we lose more water in our urine when we get older. So even if we took the nasal spray to a small person, which is the antidiuretic hormone, our kidneys would not be able to respond by concentrating the urine effectively. And we'd still have to pee at night. And that's been my experience. When a new drug came out, the nasal spray, many of my patients were started on it by their primary care physicians or by somebody else that they saw. And then they ended up in the hospital with hyponatrenia and with delirial. And I would ask them, did it help with your nocturian? They said, no. And I'm like, well, that makes sense. That does make sense. I've never-- I've used Desmo Press in the antidiuretic with, in connection to some of my younger patients that are struggling with nighttime bedbiting. And so that makes sense in terms of the flip side of some of the apoptosis or the reduction of the antidiuretic, why you're getting-- I didn't actually ever know that. I thought it was like the prostate or there was a weakening of the pelvic floor or something. It's normal aging changes. Interesting. And then children, the brain is not mature enough yet. But they have not developed enough of the brain cells to produce the antidiuretic hormone. Interesting. And some of our children developed it earlier. And others take a little longer. And that's OK. Yeah. What-- so talk me through. So we get a call from a patient for any myriad of reasons, like whether that's hypertension or even altered mental status, or they're saying they have smelt, foul smelling urine. And this culture in the nursing home is like, oh, we just got to get a UA or a urine culture. Walk me through kind of your thought process of helping rule out and identify whether this is dehydration related versus some sort of question. Yeah, because so many of the calls in the middle of the night is because the family says, oh, she's got a UTI. Because whenever she gets mental status changes or delirious, she's always had a UTI. And I would ask a little bit more history what's going on. Oh, the urine smells really strong. Well, a strong smelling urine is due to dehydration, not due to an infection. Because the bacteria in a UTI do not cause a smell. Yeah. So I will then ask how much has the patient been drinking? And most of the time they cannot tell me. But most of the time it's not enough. So I will tell the staff, go ahead and increase the fluid intake. And it-- And this is oral intake. Yeah, it's absolutely only oral intake. I'm not an advocate of IV fluids because it sends patients into heart failure. Two thirds of IV fluids are third space and send them into heart failure. So just oral fluids. And if they don't like to drink, figure out what they like and just urge them, encourage them to drink every few minutes, a sip or two, whatever they will take. But get in at least two liters a day. That is the minimum that our older adults need. Because-- This is more than I probably drink in a day, too. I probably dehydrate, too. Because you're young, you can tolerate it. Because you can concentrate, you're-- There you go. And older adults just really can't. So we really need to push to quite a lot. today. And so when we're talking about it, yeah. No, just generally these nighttime calls we're getting in or like either they're halted or like their hypotensive, like how do you make sure this is not an acute something that needs like correction immediately versus like we have another cause like we just started in a diuretic or we just started. The symptoms of delirium, the symptoms of urinary frequency and in dysuria because a concentrated urine is irritating to the bladder. So it will cause patients to have to go more frequently or more urgently. So increase and fluid intake solves the issue in more than 99% of my patients. So I engage the families, especially because sometimes the nurses say oh the families really want to get a urinalysis or to put a patient on an antibiotic, because it always works. And only this antibiotic will work and I would say let me talk to the family and if I'm in the building I will walk upstairs and talk to the family and I will say let's try increasing fluids for the next night, overnight or the next 24 hours. And then I will re-evaluate the patient tomorrow and if they're still not doing well then we'll get a urinalysis. But in all of my patients they usually do well and even if they have a UTI you need to increase fluid to then wash out the bacteria. And I have convinced all of my family so far. Yes, dehydration was the issue and it gives them something to do to help the staff hydrate the patient by encourage them to drink and give them whatever they like. Yeah, one of the questions I was like push for our providers is like if they're calling for hypertension based off of one blood pressure reading. Like are they are they are they symptomatic? Hypotensive. Like I think culturally we also think oh if a patient is hypotensive we're in crisis or in a secure nature we have to send him to the hospital. But like are they otherwise asymptomatic? Then we need to be pushing for fluids. And one of the trends that I see especially in our older population is that maybe some of these providers are cutely trained and so they're like I'll start an IV, give them fluid. Which like you say is not the answer with this population is like trying to increase this oral supplementation fluid. Very important. Occasionally I will do hyperdermal places for acute event. Yeah. But then I have a discussion with the family about end of life because if the patient cannot maintain their own hydration anymore then it's time to talk about calling it quits and dying of dehydration is a very humane way of dying. Right. And that I think is one of the reasons why we lose the sense of thirst as we get older so that when we develop dementia and we're confused we don't feel thirsty or hungry at the end of life. We just fade away. Yeah. And it's kind of the natural sort of or so life of. But hypertension is always due to dehydration and older adults. Yeah. So what I always cringe at when then providers scale back the anti-hypertensives instead of increasing the fluid intake. So yes do you do diligence get some labs to make sure that it truly is high-potentio due to dehydration and indicators are hypernatremia or hypoenatremia and we'll talk about that in a second elevated be your creatinine ratio but especially if you have osmolarity that is the gold standard for dehydration. So what I'm and now you kind of outline briefly are you reaching more for like renal function? Are you doing a full BMP or you doing a CMP or you get a BMP because it costs it's the same. Yeah. And then I get a little bit more information. Okay. And the reason I need that is because most medications that older adults take can cause hypoenatremia and the biggest offenders are all psych drugs except for buproprium and all the blood pressure medicine except for beta blockers and health and tone waters. So all the RAS medicines ran in angiotensin system like acenhibitors, arms, spironolactone, etc. They all cause hypoenatremia. So whenever you see hypoenatremia it's always medications because our older adults don't drink enough to cause polydipsia as just like with Jenny calls of hypoenatremia. So don't worry about fluid restriction instead look at the medicines but if the patient needs a certain medicine that causes the hypoenatremia I'm fine with it because most patients are totally asymptomatic with their hypoenatremia. So I don't even manage it and yesterday somebody talked about C H F and about electrolyte management and they also said oh they have a sodium 121 and they're doing fine I don't mess with it. So don't get excited about it. Treat the patient not the numbers. I think that's always important especially on from an acute setting or you're getting a call and they're like they're hypoenatremic and they're delirious. I think in a acute setting that's an easy answer but we often see older adults admitted to the hospital for hypoenatremia. But they've been there forever. So it doesn't really matter. So look back and see what's their history. Yeah. Is the patient doing okay and then treat the patient not the numbers. Yeah and I think one of the things is we're trying to overall do what's best for the patient rather than just sending them to the hospital which really is not the best thing for this population. They get confused, delirious, they climb out of bed and break a hip. Yeah. It's not a good thing. So I like your approach of like are we taking enough oral hydration? Give increased oral hydration. Get some labs so you can source through some of this. A really important is like looking is there any change in diuretics recently? Is there any change of an anti-hypertensive recently? Most of them probably haven't been touched for a year or more or looked at. And so rather than kind of acutely jumping to IV fluids or an acute referral to the hospital like how much of their drinking what is their status right now? What does the patient look like? Not the numbers and hopefully start increasing that oral hydration. So the other key to the reason older adults need more fluids and especially early in the day is because of cross linking off elastin and collagen that makes our tissues less elastic. It's most apparent in this on the skin. I mean look at the difference between your skin and my skin. You look great. I'm older but I'm not as old as many of our patients. Yeah. So due to this cross linking off elastin and collagen our tissues are less elastic and that causes our veins to be less elastic so they don't bring the blood back to our heart as effectively and we lose one to two liters of blood when we get up in the morning into our legs. So if we don't replenish that fluid drop into our lower extremities by drinking more fluids early in the day we're going to get dizzy and fall on the way to the bathroom. So I encourage my patients to drink a liter of fluids within four hours of waking up and I tell my patients when you get wake up in the morning you sit on the side of the bed and you drink a pint of fluid if you can but at least a cup. In my presentation tomorrow afternoon is going to go into great detail on that but by starting the fluid resuscitation at the side of the bed it gives you a body enough time to equilibrate that shift and it starts your fluid resuscitation and then drink the fluids every hour until you have a whole quart or a liter and within four hours of getting up and then another liter by lunchtime and then you don't have to drink much the rest of the day so you don't have to be all night. Yeah so maybe break it down for simpler for maybe some of our newer providers that are just out of training like you get your BMP back and you're concerned about the hydration you're trying to roll out some of the big vets scary stuff. What is it that you're looking on the lab that would maybe indicate to you that there is dehydration versus oh there's something of the fariest maybe going on the labs. Let's start with the BUN because it's in the left of my corner. Yeah. The fish diagram. Yeah. So if the BUN is elevated that gives me concern. Yeah. If the sodium is elevated that gives me concern but if the sodium is low I'm still concerned because hyperbolemia or dehydration can cause low sodium. Right. So our kidneys are very good at holding on to sodium because historically our diet was high in potassium with foods and vegetables and we didn't have any access to salt unless we live next to the ocean and most of us didn't. Yeah. It was too dangerous. So our kidneys evolved to be very good at holding on to sodium and getting rid of potassium. Now with the gonads moving into town we get much more salt than we ever needed and we don't get enough potassium because we don't eat enough fruits and vegetables. So it's really critical to reduce the salt intake in our older adults to protect their hearts, their brains from the stroke and to control their blood pressure. And at the same time, watch for sodium, low sodium. And it's not a solved problem by giving salt tablets or increasing the salt that the table is not going to make any difference to high point A3. Yeah, because remember what I said, it's always due to medications. And because the aging kidney cannot hold on to sodium as good as a young kidney can, because we used to were very good at that. But an aging kidney cannot hold on to sodium as effectively and get rid of potassium as effective root. So we tend to have more high point A3 and older adults, either because of medications or because they're not drinking enough. So if you don't produce the kidney enough, it cannot work to hold on to the sodium. So high point A3 can be from low sodium, is threatening combination with medications. So I look at the field in preadlin ratio, but sometimes the preadlin can be elevated to the colline burial failure, but it can also be due to dehydration. We did a study at our nursing home looking at the prevalence of dehydration. We found a prevalence of 75%. Really? Yes. Over three years, we brought that prevalence down to 36%. And most of the patients that had a diagnosis of chronic renal failure did not have chronic renal failure anymore, once we had rated them. Really? So just because the creatin is elevated doesn't mean that it is chronic renal failure. So look at the hydration status of the patient. Make sure they're increasing their fluid intake. If the creatin goes down, right. And if not, then you can call it chronic renal failure. Gotcha. Cool. And usually I tell my patients to drink two quarts a day, a fluid, whatever they like, including coffee. Coffee is not bad. As long as you drink it all day, every day, you're a receptor scaled back. And it doesn't-- it is not that red again, if you want. If you did it intermittently, then you have to add a few extra glasses of water. So drink two quarts a day. And then when they come back for follow-up, I ask them, so how much are you drinking? When are you drinking it? If I get a good enough story, then I believe they are really drinking two quarts a day. Then I recheck that B.O. and creatinine ratio or the BMP to make sure that that's enough. Occasionally, but I can count the number of the thousands of patients I've treated over the 30 plus years. And one hand that patients needed more than two leaders to maintain their electrolytes. Interesting. So it's not a heavy lift to get them to drink two quarts. Yeah, I think the other aspect in its every provider's favorite thing is the documentation here, right? Like, we need to-- one thing I think we all can improve on as providers is making sure that we're documenting that we thought about all of these things. Like, we got a lot for specific reason, and we're encouraging intake of fluid. And consistently in our orders, we should be telling nurses that they need to increase their fluid intake. And then making sure we're documenting that we thought about medications, we thought about dehydration, we fool the appropriate labs. And that-- so we can explain our kind of medical decision making in this process. So-- Exactly. --which I as a provider need to improve on, too, because sometimes you get really busy. Yeah, and it's hard. And you're dealing with five different problems. And dehydration is only one of them. That's really critical that we just document the medical decision making in the assessment and plan to also increase our billing. Yeah. And without that-- A appropriate billing. Yeah, appropriate billing. Because if we cannot justify what we did and why we did it to increase the billing level, then we should not bill a level four. Right. Because we need to make sure that it's explained. Plus, then it also explains to the nursing staff that usually read our notes why we're doing something. And that really will go a long way to improving the care of our patients and to reduce the phone calls in the middle of the night. If the nursing staff is empowered to make some changes, like increasing fluids in somebody becoming deliveries. And it's something you can easily do. Yeah. Like it's easy. I think the other thing is providers probably are thinking about these things, like good providers. You think about these things kind of quickly and you kind of checklists in your mind, but we're making sure we're including that in our documentation as well. So a couple more things. Please. Yeah. Absolutely. So the Institute of Medicine says that women need 2.7 liters a day through men, 3.7 liters a day. I say a minimum of two liters. And the Institute of Medicine also then later came out as stating that we should just use sourced as our guy while in older adults, we cannot go count on thirst. So make sure your patients are getting in a fluids and our staff and the facilities. And whenever we come to see the patients, we offer them something to drink. Make sure there is something at the bedside in the reach of the patient if they're moving around in their wheelchair. Make sure they have a bottle on their wheelchair so they can drink at the time. And then we need to remind them throughout the day. The other thing is that a few years ago, a study came out of Canada that said that we don't need to restrict the sodium in our patients' heart failure. And that actually, too much sodium restriction is actually no better than no sodium restriction. It's interesting. What is this study? So it was a study out of Canada. And we can link it up below on the podcast, OK? And in compared the average intake of sodium in Canada, which was 2.5 grams, compared to over 3.8 grams in the US. So the average US person takes in six grams of sodium a day. I mean, vastly different amounts. So the Canadian study reduced the intervention group to 1.5 grams, compared to 2.5 grams for the control group. And showed no difference, of course not. But I would be happy if my patient got down to 2.5 grams in a day. And that would solve all of their problems with their heart failure. So that is the criticism of that study. When somebody says, oh, the study showed no difference from sodium restriction on heart failure. Oh, it does. It makes a big difference in the US where people use just a lot of salt. I-- after the podcast, I need to go and drink more water. After a conversation today. But I'm really so happy to have had you on our podcast. And we love working with you. The education you provide. And so we're excited to keep working with you. Anything else you want to say? I'm hammering home increased oral hydration, especially among our patients. And making sure we're looking at these various causes of what? UTI or delirium or hypotension could be simply related to dehydration. Yeah, totally. Which is an easy kind of intervention for us to make. Exactly. And just encourage your patients to drink frequently all throughout the day. Tell us about your chapter in your book. Yeah. So I wrote a chapter on jury metrics in the family medicine textbook by Dave Raekel. And I'm looking forward to it coming out. But I'll be glad to share it with you on your education website, because I have a complete copyright over it. Yeah. And I plan to write a book and elaborate on the chapter. But the chapter is very concise. And since it's in digital format, you can just search something and use it as a reference in your office. Awesome. Well, I hope to have you on the podcast again sometime. Yeah. So I've learned a ton today. So hopefully those who are listening to our podcast will hear a ton too. So thanks again, my friend. Dr. Henry. Good to have you. Yeah. So yeah. Before we conclude, huge thanks to our sponsor, Vital Care Connect. Whether you're burning the midnight oil or just trying to survive another 2am call, Vital Care Connect provides on-call medical director support whenever you need it. Nights, weekends, and holidays with coverage nationwide, they're leading the way and post-acute care, elevating quality, expanding access, and supporting well-being for all. Learn more at vitalcare.org. Thank you for joining us for this episode of Sniff This. Share this show with your favorite CNA or anyone who's survived in all staff meeting fueled by cold coffee. Until next time, I'm Chance in skilled nursing. If you sniff something, say something.