Water intoxication in nursing home
METHODS TO IDENTIFY polydipsia among elderly nursing home residents have been imprecise or absent. Typically persons with polydipsia are not identified until a life-threatening water intoxication episode occurs and they are transferred to an acute care facility for medical and psychiatric management. Yet these individuals are exhibiting behaviors consistent with polydipsia for weeks or months and are simply not identified by most health care workers. Even today, nursing home employees are not familiar with or skilled in identifying these symptoms and/or how to manage polydipsia. Routinely, these workers are trained to force fluids to prevent dehydration so commonly found in the elderly that no one questions water-seeking behaviors in residents.
Contributing to this dilemma is the fact that certified nurse aides who have limited or no knowledge about polydipsia provides the majority of care. Also, not all nursing homes routinely employ psychiatrists and/or psychologists to manage the residents’ mental health needs. Thus, the primary aims of this study were to describe the personal and health-related characteristics of nursing home residents with one or more psychiatric diagnoses and the subset who screened positive for polydipsia and to describe the prevalence of screening positive for being “at risk” for polydipsia. We also report on the behavioral characteristics and symptoms associated with polydipsia as identified in the literature and contained in the screening tool.
Literature review
Polydipsia is a condition whereby individuals consume 3 or more liters of fluid per day, and in extreme cases, 10 liters (De Leon, Verghese, Tracy, Josiassen, & Simpson, 1994). This condition may be chronic or episodic with symptoms ranging from mild to severe. When coupled with impaired water elimination, water intoxication or acute hyponatremia causes considerable morbidity and mortality (Shutty, Hundley, Leadbetter, Vieweg, & Hill, 1992). On admission to an acute care facility, polydipsia is identified by a serum sodium level below 135 mEql/L. Excluding medically induced cases of polydipsia, this condition has been reported to occur in more than 20% of psychiatric inpatients with approximately 5% developing episodic water intoxication and hyponatremia (De Leon et al., 1994). Furthermore, mortality rates have been reported as high as 18.5% in those suffering from complications of water intoxication (Vieweg, Rowe, Wampler, David, Burns, & Spradlin, 1985).
Data from the 1995 National Nursing Home Survey showed that mental disorders are the second most frequent primary diagnosis accounting for 17.1% of all elderly nursing home resident admissions (National Center for Health Statistics, 1997). Patients diagnosed with schizophrenia are reported to be at highest risk for this condition; however, polydipsia has also been diagnosed in patients with other psychiatric or mental disorders (De Leon 2003; De Leon et al 1994; Hayfron-Benjamin et al 1996; Mercier-Guidez and Loas 2000; Patel 1994; Shutty et al 1992 and Vieweg et al 1994). Although De Leon et al. (1994) found that some patients with polydipsia tend to have a history of water intoxication, they also noted that the condition is not always recognized, and thus, may not be reported in the resident’s medical history.
Characteristics and symptoms associated with polydipsia
A newly developed and tested Polydipsia Screening Tool (PST; © 2000 by Sheila Reynolds) was used for this study (Reynolds, S.A., 1999. A polydipsia screening tool for nursing homes Unpublished manuscript, University of Wisconsin Milwaukee .Reynolds 1999 and Reynolds et al 2004). An in-depth discussion of the symptoms and characteristics of polydipsia along with the psychometrics of the instrument are provided elsewhere (Reynolds et al., 2004).
Medication side-effects that may mimic polydipsia
According to the literature, nursing home staff must conduct in-depth assessments beyond symptoms and behavior because some medications may produce side effects that mimic polyuria and/or polydipsia, in which case, different management strategies are required. For example, medications that increase the antidiuretic hormone (ADH) or induce the syndrome of inappropriate antidiuretic hormone (SIADH) are known to affect water balance in the body. Drugs that increase ADH include some anesthetics, carbamazepine, clofibrate, isoproterenol, nicotine (in cigarettes and smoking cessation medications), phenobarbital, tricyclic antidepressants, and the anticancer drugs vincristine and cyclophosphamide (Porth, 2002). ADH is likely to be released when there is a drug induced hypotension (Raskind et al., 1987). Thiazide diuretics (chlorothiazide) increase ADH secretion causing the kidneys to increase water reabsorption (Porth, 1994). Vieweg et al. (1994) recommended against thiazide diuretics in psychiatric patients for control of hypertension because they found it induced water intoxication in individuals diagnosed with schizophrenia.
Riggs, Dysken, Kim, and Opsahl (1991) reviewed various studies that linked different psychotropic drugs with hyponatremia. These investigators reported that hyponatremia was found in patients taking thiothixene (Navane, Pfizer, New York, NY), haloperidol (Haldol, Ortho-McNeil, Raritan, NJ), and chlorpromazine (Thorazine, SmithKline Beecham, Pittsburgh, PA; antipsychotics-typical); amitriptyline (Elavil, AstraZeneca, Wilmington, DE) and desipramine, (antidepressants-tricyclics); Parnate (SmithKline Beecham; antidepressants-monoamine oxidase inhibitor); and carbamazepine (Tegretol, Novartis, Hanover, NJ; anticonvulsant).
Sulphonylureas (antidiabetic agents) induce SIADH, which results when there is a failure in the feedback system and ADH secretion continues despite a decrease in serum osmolality (Porth, 1994). Diabetic agents found to induce SIADH include tolbutamide, glyburide, tolazamide, acetohexamide, metformin, and phenformin (Vieweg et al., 1994). More recently, selective serotonin reuptake inhibitor (SSRI) antidepressants have been implicated. SSRIs such as fluoxetine (Prozac, Eli Lilly, Indianapolis, IN), paroxetine (Paxil, SmithKline Beecham, Pittsburgh, PA), sertraline (Zoloft, Pfizer, New York, NY), and fluvoxamine (Luvox, Solvay, Marietta, GA) can induce SIADH shortly after the initiation of therapy, especially in the elderly (Miller, 1998). Lithium, a mood stabilizer drug, can also produce polyuria and secondary polydipsia because it induces nephrogenic diabetes insipidus (Patel, 1994).
Tags: Nursing home