Dehydration and Malnutrition in Nursing Homes: Warning Signs & Treatment
In last week’s blog, we discussed the legal obligations nursing home operators have to their residents regarding the prevention of malnutrition and dehydration. But how are these conditions identified in the first place? And what can be done to treat them?
For health professionals, knowing how to spot the early warning signs is a prerequisite for making a diagnosis. For family members, common symptoms can alert them to failures of care. From a legal perspective, identifying the signs of dehydration and malnutrition is crucial to building an elder abuse case. Symptoms often develop slowly and may easily be missed until they become dangerous — which is why careful documentation of the early warning signs can prove vital in establishing abuse and neglect.
With that in mind, let’s look at some of the tell-tale signs of malnutrition and dehydration, how they can be confirmed through medical testing, and what treatments should be implemented by nursing homes.
Key Signs and Symptoms of Dehydration and Malnutrition
Confusion, Delirium, or Cognitive Decline. Dehydration and malnutrition can worsen existing memory or cognitive problems—or even cause new ones. This can manifest in a number of ways, including confusion, trouble focusing, agitation, or sudden changes in mental state (delirium). Delirium is a medical emergency but often reversible if the underlying cause (like dehydration) is treated quickly. Look for symptoms such as hallucinations, extreme restlessness, or disorientation.
Weight Loss. Unexplained or rapid weight loss is one of the clearest indicators of malnutrition. For example, if a resident loses 10 pounds in two months or more than 5% of their body weight, it could be an indicator of poor nutritional care — and a consequence of neglect.
Dry Mouth, Lips and Throat. A dry mouth, cracked lips, or difficulty swallowing or speaking may indicate that the person isn’t getting enough fluids.
Fatigue and Weakness. Lack of fluids or nutrition often causes tiredness and weakness. If a resident seems unusually lethargic or struggles with daily tasks, poor hydration or nutrition may be the cause.
Low or Dark Urine Output. Two common signs of dehydration are i) dark-colored urine, and ii) a noticeable drop in urine volume. Tracking the color and frequency of urination helps catch dehydration early.
Poor Skin Elasticity (Skin Turgor). Dehydrated skin doesn’t bounce back when gently pinched. If the skin on the back of the hand or forearm stays “tented,” it may signal fluid loss.
Sunken Eyes. Eyes that appear hollow or recessed, often with dark circles, are a clear sign of severe dehydration.
Digestive Problems. Dehydration can cause constipation, while malnutrition might lead to bloating, diarrhea, or indigestion. These are all signs that the resident is not getting proper care.
Swelling (Edema). Although less common, malnutrition can lead to swelling – especially in the legs – due to low protein levels causing fluid buildup in the tissues.
How Is Dehydration Confirmed by Lab Testing?
Several lab tests can be used to diagnose dehydration and malnutrition, generally by evaluating fluid balance, kidney function, and electrolyte levels. Common tests used in the diagnosis of dehydration include:
Blood Urea Nitrogen (BUN) levels show how well the kidneys are removing waste. The normal range is 7-20 mg/dL. Elevated BUN levels can indicate dehydration.
Another measure of kidney function is creatinine levels, which should be 0.6–1.2 mg/dL for women and 0.7–1.3 mg/dL for men. BUN and creatinine evaluations are used in conjunction to diagnose dehydration. An elevated BUN-to-creatinine ratio (usually above 20:1) indicates dehydration rather than kidney disease.
An electrolytes panel can identify elevated levels of sodium, potassium, chloride, bicarbonate, and other key electrolytes. High sodium levels (above 145 mEq/L) are a hallmark of dehydration. Severe dehydration can raise sodium to dangerous level, causing confusion, weakness, seizures, or coma.
Urine specific gravity (USG) testing can be used to check urine density and kidney function. A high USG (above 1.030) indicates possible dehydration. Urine osmolality testing is another way to check urine concentration.
High levels of hematocrit or hemoglobin may signal dehydration, since the blood becomes more concentrated when fluids are low. The normal hematocrit range is 36–48% for women, and 41-50% for men. The normal hemoglobin range is 12–16 g/dL for women, and 13.5–17.5 g/dL for men.
Dehydration can raise blood sugar levels, especially in people with diabetes. Normal fasting blood sugar is 70–100 mg/dL. Anything above 180 mg/dL is considered hyperglycemia, which can lead to serious complications like diabetic ketoacidosis.
How Is Malnutrition Confirmed by Lab Testing?
Lab tests to diagnose or confirm malnutrition include:
Albumin and Pre-albumin. Low levels of albumin and pre-albumin in the blood are signs of malnutrition.
- Albumin should be between 3.5–5.0 g/dL. Levels below 3.5 suggest long-term poor nutrition, especially in those with chronic illness.
- Pre-albumin normally ranges from 15–36 mg/dL. Levels below 15 mg/dL are a more immediate sign of recent or acute malnutrition.
These proteins help keep fluid in the bloodstream. When levels are too low, fluid can leak into tissues and cause swelling (edema), which is a common result of ongoing poor nutrition.
In addition to being a sign of dehydration (see above), electrolyte imbalances can indicate poor nutrition.
Hemoglobin testing is also used to detect anemia, which is caused by malnutrition. Low hemoglobin levels may indicate anemia.
Treatment
Rehydration is the primary treatment for dehydration. Oral rehydration solutions with balanced fluids and electrolytes is the preferred method of rehydration in mild to moderate cases. Intravenous administration of fluids may be necessary for faster recovery in severe cases.
Monitoring is essential to avoid over-hydration, especially in residents with heart or kidney problems.
Addressing malnutrition requires a tailored approach depending on the resident’s needs. This may include the provision of high-calorie, nutrient-rich foods, with supplements where necessary. Again, close monitoring and reevaluating and adjusting care plans as the resident’s condition improves is paramount.
Left untreated, these conditions can quickly lead to serious complications like infections, organ failure, or death. Timely intervention is both a medical necessity and a legal duty of care in long-term care settings. Failure to act may not only endanger the resident but also serve as evidence of neglect.
Educating staff, residents, and their families about the importance of adequate hydration and nutrition is an essential part of effective care. Caregivers must be trained to identify the early signs of dehydration and malnutrition, and to apply and monitor appropriate rehydration and nutritional support measures.
This knowledge should also be shared with residents and their families, equipping them to recognize potential issues and advocate for timely and appropriate interventions.
If your loved one has suffered dehydration or malnutrition in a nursing home or other long term care facility, a dedicated elder abuse attorney can help you determine whether elder abuse has occurred. For a free consultation with an elder abuse attorney in Los Angeles, San Francisco/Bay Area, or Sacramento, contact Dudensing Law here.
For Clients