Essaying the Situation
Monday, September 06, 2004
Water Whichery
    "Wouldn't it be great if there was such a thing as a manageable portable saline drip IV for old people, as easy to use as portable oxygen, so you wouldn't have to constantly worry about Mom's hydration level?" That's MFS's comment, made well over a year ago when I was moaning over the phone about the trials and tribulations of keeping our mother adequately hydrated. I agreed with her, yes, it would be better than great. It would be a relief.
    I became aware of hydration problems with my mother, and the elderly, dramatically. Before September of 2002 I was barely aware of how much fluid she consumed, or, better expressed, how much she didn't consume. During the late summer of that year her energy level dropped to almost nothing. She spent most of her time in bed, despite the fact that we were regularly and frequently entertaining family visitors. We were in Prescott at the time. I threatened her repeatedly with canceling all visitors and taking her down to her PCP, but she sturdily declined and, well, it seemed as though there was always another visitor waiting in the wings and that their visits were at least as important to my mother as a doctor visit, probably more so. I made an appointment with her PCP to take place after the last family visitor. A week before the appointment my mother's feet began to swell, unheard of for her previous to this. We headed down on an emergency appointment to see her PCP. He took blood and immediately put her on Prednizone and furosemide to relieve the swelling, under the assumption that not only was fluid shifting unnaturally but that she was severely over hydrated. While the fluid shift did apply to her she was, in fact, dehydrated. Within less than 24 hours the combination of the medication and her dehydration caused her blood pressure to crash. She was whisked to the hospital under the medical assumption that she was suffering an episode of that ever mysterious, ever handy diagnosis, TIA. The non-alternative medical community has never admitted that she suffered a blood pressure crash due to radical dehydration. I learned this from MPS and a friend of mine, both of whom were kidney dialysis techs and recognized, immediately, from my description of the event, what had actually happened.
    We'd both been scolded about my mother's apparently permanent dehydrated state in the fall of 2000 when we had her first appointment with her current clinic. That PCP, a specialist in gerontology who has since retired, pointed out that adequate hydration should plump my mother's skin in exactly the same way mine plumps. "All those wrinkles you have on your arms and legs?" he accused. "Those aren't from advanced age, those are from dehydration. Your skin should be as smooth as your daughter's, as smooth as mine. Drink more liquids! And you," wagged an accusatory finger at me, "keep after her! There's no excuse for this!"
    I took him seriously but modified his observation. My mother started the typical elderly drying and wrinkling of the skin very early. I had a history with her and I knew that she couldn't possibly have been running dehydrated for what, then, would have been about 30 years. I began monitoring her liquid intake, though, and realized that she drank very little, not much more than sipping from a constantly refilled cup of coffee. I got on her case and she drank a little more. Her health was robust, though, despite some minor problems which were being addressed. Her energy level was high. Her ability to recuperate from health problems was superior. At that time, as well, she still had the remnants of a sense of thirst and it was not uncommon, a couple of times a day, for her to fill a glass of water from the tap and drink it down in one fell swoop. Within a couple of weeks she and I both forgot about the dehydration issue.
    She's older, now. She's lost more of what little sense of thirst she had and, with it, her habit of sipping anything, let alone coffee, throughout the day. I noticed all this after the blood pressure crash. I've been her frantic fluid manager since.
    Dehydration is such a difficult issue that even physicians can't come to terms with it. The guidelines her former PCP used were respected in their time. Now the guidelines are different, which I found out, much to my surprise, when sometime between June 8th and August 1st of this year I accidentally and dangerously over hydrated her. I'd been judging how much liquid she needed by the tenting of her skin and how severely the folds of skin around the front of her calves hung. I tried to take into consideration that she's lost a good 30 pounds since August of last year and her skin, not being as elastic as it was when she was in her prime, would, of course, appear more ragged than a year ago. But, my calculations were faulty. As a result, throughout the last several months I'd established a habit to which I referred as "water torture": Harassing her into drinking lots of liquid all day long, as, according to the guidelines of the day, she never, ever looked adequately hydrated. For the most part I did not over hydrate her. However, finally, I did. When this was brought to my attention by the neurologist team who tended her during her stay in the hospital early this August, I was aghast. They gave me completely revised guidelines regarding the appearance of tenting in the elderly which are based on the fact that medicine now recognizes this as an inadequate measurement, considering that the elderly typically have inelastic skin. I was even visited by two members of the hospital administration because I had complained about the hospital dehydrating her in early June during which she was on a 24 hour saline drip. I was lectured about how my guidelines were way off the [new] chart.
    The final verdict was, "Let her drink when she's thirsty." Herein lies the problem. She's rarely thirsty, even when she's severely dehydrated.
    Thirst is a curious sense. I've thought about why Ancient Ones lose their sense of thirst and the physical discomfort that accompanies dehydration of a person in her prime. It makes sense to me that this is the way of Nature. As beings dependent on water age and become less capable of independent survival (or, in the case of social species, need more social resources in order to survive than a colony can safely provide), Nature probably provides for an easy death by diminishing several of the senses linked to replenishment including hunger, suffocation and thirst. Nature is known for her ability to turn pain triggers off when relief of that pain by treating the cause is beside the point. It is certainly common for the terminally ill to decide to euthanize themselves by refusing nutrition and hydration. It has been documented that euthanistic fasting and dehydration do not cause discomfort. Nature, though, is not infallible. My mother has, indeed, lost most of her sense of thirst for water but she has lost none of her thirst for life. She may not grasp the glass, but she grasps time, moment by moment, hand over hand, greedy to live one more day. This is one of the components that makes the hydration issue ticklish for a dedicated caregiver.
    There is, as well, the added problem with which medicine has not come to terms: What comprises adequate hydration in the elderly. A good example is that my mother was put on fluid restriction during her early August hospital stay in order to raise her sodium level. Very low sodium levels can cause neurological problems that mimic stroking and a host of other neurological disorders, a very competent neurologist explained to me. The evidence underlined this bit of knowledge. Within 24 hours her sodium level had returned to normal and the collapse of her right side reversed itself rapidly thereafter. Aside from being very weak and needing intensive short term therapy in a skilled nursing facility, some of her strength and many of the skills she'd temporarily lost, such as her ability to hold eating utensils and her ability to use her right leg in walking, all of which led me to believe she was mini-stroking, reversed themselves almost immediately. The other debilities reversed themselves in short order. The hospital kept her on fluid restriction (2000 ccs, approximately 2 quarts, most of which she can shed overnight without effort) for four days and nights. In addition, they passed the restriction on to the SNF. The result was that, by the weekend my mother was so constipated that, in order to cleanse her, the SNF administered the laxative dose of Phillip's Milk of Magnesia while continuing to keep her on fluid restriction. Over night they had an entire day of accelerating mess on their hands. At this point they decided she was, indeed, dehydrated, took her off fluid restriction and told her she could drink as much as she wanted. By now you know how dangerous that direction is. She rarely wanted to drink anything. I warned both staff shifts that leaving it at this was not going to hydrate her. They didn't believe me and, of course, I wasn't able to get enough fluid in her when I visited to take the edge of her dehydration. Finally, I wrote a letter to the medical director, also my mother's assigned physician at the SNF, and the staff, insisted that it be put in the chart, part of which addressed the fact that if they wanted my mother to drink liquids they were going to have to continually check on her and hang out in her room to make sure she drank them. Luckily, they did.
    I think that a great deal of this confusion over how much water one "should" drink is firmly rooted in U.S. society in particular and certain other western societies similar to ours. It has never made sense to me that one should drink water continually, even if a healthy body flushes the excess. I've followed these instructions when at my wit's end with my mother, but it's never made sense. Included in that flush are, yes, what we like to refer to and shudder over as "toxins", but the body is not discriminating and willingly flushes lots of minerals and nutrients that we need, as well. Some people are what I refer to as "water babies". I'm one. I've always loved drinking water, not just the taste of it but the feel of it settling into my cells. I take after my father in this respect. My mother, though, is the opposite. If she's going to take in water she'd rather consume it disguised in food or mixed with a flavor, usually coffee or a citrus juice and even then in moderation. Some years ago I read a book whose title attracted my eye from the "new arrivals" shelf of a local library, Mutant Message Down Under. Although much of the book was forgettable, it contained a passing criticism of "Americans" that I've retained: We are addicted to drinking fluids, primarily water, and consume far more than is necessary. When I think about my problem of hydrating my mother, I often think of this. On a daily basis I have a devil of a time determining how much hydration she needs. So does the non-alternative medical community. I think of species who get almost all their water from their food. I wonder if we aren't more closely related to those species than we are to the burgeoning water industry.
    And, now, it is becoming politically correct to take note of our elders in society. Both lawyers and the government, in the form of Adult Protective Services Agencies, are flooding television with paid and service advertisements counseling the zoned in watcher that dehydration is not only one of the prime offenses committed by care facilities and caregivers against the elderly, it is inexcusable.
    No, it's not inexcusable. I know from personal experience that it is more than easy to accidentally over or under hydrate a beloved Ancient One. It is inevitable that this will happen at some point in one's caregiving career, whether that career is vocational or avocational. The marketing director of the SNF in which my mother was recently 'theraputed' told me that these ads make her mad. I don't blame her. They scare me. Factor in my mother's lack of thirst, my frenzied and confusingly informed efforts to determine whether or not to admonish her to drink yet another glass of fluid, add a liberal dash of "old bladder" incontinence for which she is not a candidate for a surgery that often does not work anyway, and on any given day the water cops could walk into our home when I am on the wrong end of the hydration battle and I could be in water too deep or too shallow for their equally confusingly informed sensibilities. I am aware, at almost every moment of every day, that I could be accused of neglect based simply on one person's opinion in the myriad of the many conflicting opinions that exist on the issue of hydration and the elderly.
    The interesting aspect of all this is that, since I've begun to use the "new" guidelines, as well as noticing that, if nothing else is affecting my mother's blood pressure I can use that as a hydration indicator as well (with circumspection, of course), we are using fewer Depends than previously. Although she still sheds water at night and I am still washing her bedding daily, it's been weeks since I've had to wash her bedding in the afternoon after a nap and it is a rare occurrence, now, that her nightly water shed reaches her pillow. As well, although I still have to remind her to drink some liquid during the day, especially since her mind, unfortunately, did not consign the directive, "Let her drink only when she's thirsty", to the chasm of her faulty short term memory, I am not at her constantly anymore and am much more relaxed about giving her body an entire day to hydrate itself rather than insisting that she be hydrated within a few hours after awakening. She is happier, I am less stressed, and I expect our electricity bill to be lower next month. I owe all of this to the non-alternative medical community's rethinking the water issue over the last few years, although it's been hell waiting for them to do so.
    Where do I stand on the portable IV idea now? I'd like, first, to see lots more research done on the issue of hydration and the elderly, covering such issues as lack of thirst and its relation to what may be lack of need. I'd like to see both the non-alternative and the alternative medical communities reevaluate water health policy in light of the possibility that, in this country in particular, we've been freaking over water consumption for the last couple of decades and we need to stop. Ultimately, I'd like someone to invent a gadget, similar to the new fanny pack oxygen concentrators, that is truly portable, takes frequent, non-invasive sensor readings of a person's hydration level, say, once very half hour or so, then noiselessly, with the aid of a constantly renewable solar cell battery, concentrates water from hydrogen and oxygen in the atmosphere, painlessly and unobtrusively delivering it to the wearer when needed. Simply put, I want a Star Trek device for my mother, and for me, should I live long enough to need it. And, I want it covered by a health care industry that leaves out no one.
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