Hypodermoclysis in Long-Term Care: Utilization Patterns and Association With Staffing Levels

Hypodermoclysis in Long-Term Care: Utilization Patterns and Association With Staffing Levels | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Hypodermoclysis in Long-Term Care: Utilization Patterns and Association With Staffing Levels Nicolas DENIAU, Oceane LELONG, Christine FORASASSI, Frédéric BEHAR, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8558737/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract PURPOSE To determine the prevalence of hypodermoclysis use in long-term care (LTC) settings, describe associated clinical practices, and examine association between hypodermoclysis use and unit-level characteristics. METHODS Cross-sectional multicenter study based on data collected on a single day. Resident data from LTC units were collected by the supervising geriatricians of 27 LTC units affiliated with the Assistance Publique–Hôpitaux de Paris (AP-HP). Descriptive statistics summarized hypodermoclysis practices. A multivariable logistic regression was performed to assess the association between staffing levels and the likelihood of receiving hypodermoclysis. RESULTS Among 748 residents, 21% were receiving hypodermoclysis, with prevalence varying significatively across centers (14%–36%). Hypodermoclysis has been prescribed for a median duration of 95 days on the study day. It most commonly involved dextrose solution, prescribed at 500 mL per day. Factors independently associated with hypodermoclysis use included the resident-to-nurse ratio (OR = 0.73), the resident-to–nursing assistant ratio (OR = 1.75), and physician staffing (OR = 0.70). CONCLUSION Findings reveal heterogeneous use of hypodermoclysis in LTC, often at low volumes and over prolonged periods. Given the association between staffing levels and hypodermoclysis use, strengthened interprofessional engagement and collaboration may be needed to optimize hydration practices. Hypodermoclysis Dehydration Aged Long-term care Personnel staffing and scheduling Quality of health care KEY SUMMARY POINTS Aim: Describe hypodermoclysis practices in long-term care and the associated institutional factors. Findings: Hypodermoclysis is widely used in long-term care for prolonged, low-volume infusions. Hypodermoclysis practices vary across centers; staffing levels influence use. Message: Results suggest hypodermoclysis resembles routine care, raising ethical concerns; staffing levels are key to hydration and overall quality of care in long-term care. 1. INTRODUCTION Dehydration is difficult to detect and prevent among institutionalized older adults [ 1 ]. Because clinical signs of dehydration are unreliable in older adults [ 2 ], definitive diagnosis of dehydration relies on biological measures in this population [ 3 ]. Using the diagnostic criterion based on measured osmolality, as recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN) [ 4 ], the prevalence of dehydration in institutionalized older adults is estimated at 34% (range 3%–89% across studies) [ 5 ]. Dehydration is associated with increased healthcare utilization and healthcare expenditures among older adults [ 6 ]. Older studies estimated the cost of dehydration among older adults in the United States to be approximately one billion dollars [ 7 ]. A commonly cited reason for the high prevalence of dehydration in institutionalized older adults is that they often do not receive adequate fluids during the day, and those unable to drink independently do not receive sufficient assistance [ 8 – 10 ]. Several studies have examined the impact of staffing levels on dehydration in institutionalized older adults; however, the level of evidence remains low, and findings are inconsistent [ 11 ]. Shin and Huyn reported that higher staff turnover is associated with a greater risk of dehydration among institutionalized older adults [ 12 ]. Reed et al. suggested that a higher staff-to-resident ratio is associated with a lower risk of dehydration [ 13 ], although this finding was not replicated in other studies [ 12 , 14 , 15 ]. Conversely, Namasivayam-MacDonald et al. found that having more staff present in the dining room was associated with an increased risk of dehydration, possibly reflecting a higher number of residents in these settings [ 16 ]. To prevent dehydration in older adults living in residential care, ESPEN recommends implementing multi-component strategies [ 4 ]. Based on the systematic review by Bunn et al. – which found substantial heterogeneity in the interventions studied [ 17 ] – ESPEN recommends that these multi-component strategies include high availability of drinks, varied choice of drinks, the frequent offering of drinks, staff awareness of the need for adequate fluid intake and staff support for drinking [ 4 ]. Subsequent works by Paulis et al. emphasized the importance of interprofessional collaboration in addressing dehydration among institutionalized older adults [ 18 , 19 ]. When dehydration is confirmed, ESPEN recommends the use of subcutaneous or intravenous fluids in parallel with encouraging oral fluid intake, in older adults who appear unwell [ 4 ]. This recommendation for hypodermoclysis (subcutaneous fluids infusion) use is primarily based on the older review by Turner et al., which supported the use of dextrose-saline infusions [ 20 ]. More recently, International Consensus Recommendation Guidelines for Subcutaneous Infusions of Hydration have been published, although they do not specifically target older adults [ 21 ]. Evidence supporting the use of hypodermoclysis remains of low quality but suggests that it is safe and effective for treating mild to moderate dehydration in older adults [ 22 , 23 ]. Subcutaneous hydration is also less expensive than intravenous hydration [ 24 ]. Nevertheless, some authors suggest that hypodermoclysis remains underutilized [ 25 ]. Studies investigating its use in long-term care (LTC) settings are generally older and include small sample sizes [ 26 , 27 ]. In this context, we aimed to examine the use of hypodermoclysis among LTC residents and to explore institutional factors associated with its use, particularly those related to staffing. 2. METHODS We conducted a cross-sectional multicenter study based on data collected on a single day (January 21st, 2025). All residents of LTC units affiliated with the Assistance Publique – Hôpitaux de Paris (AP-HP) on the index date were included, except those who had explicitly declined the use of their medical data. AP-HP is the largest public hospital network in Europe, providing 1451 LTC beds across 14 hospitals. Spearheaded by the CLAN central AP-HP , multicentric Food and Nutrition Committee, geriatricians in charge of each LTC unit were instructed to collect a set of predefined variables for all residents present in unit on the designated study day. These variables included sociodemographic information, relevant clinical data, and specific details related to the use and administration of hypodermoclysis. Geriatricians were instructed to describe the characteristics of their unit, including available staffing and material resources. The primary objectives of this study were to determine the prevalence of hypodermoclysis use in LTC settings and to describe the associated clinical practices, including indications, type of fluid administered, prescribed volume, duration of treatment, mode of administration (continuous or intermittent), infusion site, and the use of concomitant oral hydration. The tolerance of hypodermoclysis was also assessed by identifying any reported adverse events potentially related to its administration on the designated study day. The secondary objectives were to examine whether unit-level characteristics – such as staffing (physicians, nurses, nursing assistants, nurse managers, dietitians, occupational therapists, and speech therapists) and material resources (staff training on hydration and swallowing disorders, and access to drinking water for residents) – were independently associated with the likelihood of receiving hypodermoclysis. Staffing levels were reported either as a resident-to-staff ratio or as full-time equivalents per “standard” 28-bed unit, as applicable. Costs associated with the use of hypodermoclysis were estimated from the provider perspective. A statistical plan discussed between clinicians and the statistical analyst was discussed prior to the start of the study. Descriptive statistics summarized resident and unit characteristics, hypodermoclysis use and reported adverse reactions. Continuous variables were presented as medians with interquartile ranges (25th–75th percentiles), while categorical variables were reported as counts and percentages. A primary analysis focused on identifying unit-level factors associated with the use of hypodermoclysis. Bivariate analyses were first conducted using Student’s t-test or the Mann–Whitney U test for continuous variables, and the chi-square test or Fisher’s exact test for categorical variables, as appropriate. A multivariable logistic regression model was then constructed to examine the association between staffing and the likelihood of receiving hypodermoclysis. Resident-level variables previously identified as potential confounders were included in the model to adjust for differences in clinical indication for hypodermoclysis. For all tests, the alpha-level was defined as 0.05 bilaterally, and analyses were performed with RStudio. 3. RESULTS On the study day, data were collected for 748 residents out of 1451 beds in LTC units, corresponding to a response rate of 52%. The median length of stay in the unit on the day of the study was 685 days (interquartile range: 260–1348). Residents were predominantly women and had a mean age of 85.66 years. Most were dependent for feeding or hydration (55%). Fifty-three percent had malnutrition, and 49% had swallowing disorders. Nearly all had cognitive impairment (92%). The clinical characteristics of the participants are presented in Table 1. Among the 748 residents, 157 (21%) were receiving hypodermoclysis. The prevalence of hypodermoclysis use varied significantly between centers, ranging from 14% to 36% (p < 0.001). The most common justification for hypodermoclysis was dehydration or risk of dehydration (92%). Among residents not receiving hypodermoclysis, only 6 (1%) were receiving intravenous hydration. Details regarding the presence or absence and indication for hypodermoclysis are presented in Table 2. Hypodermoclysis had been used for a median duration of 95 days [IQR: 29–230 days]. Twenty-two residents had been prescribed hypodermoclysis for more than one year, with the longest prescription lasting 1,777 days. In 10 residents, hypodermoclysis was prescribed continuously for the entire duration of their stay, starting from admission. On average, hypodermoclysis was prescribed for 24% of the stay up to the study day. The most commonly used fluids were dextrose solutions (54%) and dextrose-saline solutions (41%), while only 7% of residents received saline alone. In most cases (69%), the prescribed infusion volume was 500 mL per day. Hypodermoclysis was administered intermittently and overnight in almost all cases. The most common infusion sites were the thigh and abdomen; in 27% of cases, two infusion sites were used simultaneously. In 94% of cases, oral hydration was administered in combination (still: 18%; sparkling: 33%; thickened: 49%). Details regarding the administration of hypodermoclysis are presented in Table 2. Adverse events related to hypodermoclysis were reported in 9% of cases. One serious adverse event (abscess) was reported. Non-serious adverse events included: edema (n = 1), pain (n = 2), erythema (n = 8). The daily cumulative cost of hypodermoclysis (solution and equipment) was USD 259 for all 157 residents. When accounting for the full duration of prescription, the cumulative cost of hypodermoclysis for the 157 residents amounted to USD 54,146. Among the 27 LTC units, 41% had a “standard” capacity of 27 or 28 beds. The nurse-to-resident ratio ranged from 1:14 to 1:36, while the nursing assistant-to-resident ratio ranged from 1:5 to 1:10. The mean number of physicians per standard 28-bed unit was 0.58 full-time equivalent. The mean number of dietitians and occupational therapists per standard 28-bed unit was 0.16 full-time equivalent for each profession. Two units reported having no dietitian, and one unit reported having no occupational therapist. Only 37% of units reported access to speech therapist consultation, and 19% reported access to speech therapist rehabilitation. Reported training during the past year on hydration or swallowing disorders was 37% et 59%, respectively. All units reported access to sparkling or thickened water. In 57% of units, a water fountain was accessible to residents, and only two units reported not having a communal room for lunch. Unit characteristics are presented in Table 3. In univariate analysis, the use of hypodermoclysis was associated with a higher resident-to-nursing assistant ratio and lower physician staffing (Table 4). Conversely, the resident-to-nurse ratio, staffing levels in nurse managers, dietitians, occupational therapists, or speech therapists were not associated with the use of hypodermoclysis, nor were staff training or material conditions. In the multivariate analysis – adjusted for age, sex, weight, feeding or hydration dependency, malnutrition, swallowing disorders, and cognitive impairment – factors independently associated with the use of hypodermoclysis included the resident-to-nurse ratio (OR = 0.73), the resident-to-nursing assistant ratio (OR = 1.75), and the physician staffing (OR = 0.70) (Table 5). There was no correlation between the duration of hypodermoclysis prescription (as a proportion of the length of stay) and physician staffing (p = 0.633). Staffing levels in nurse managers, dietitians, and occupational therapists remained unassociated with the use of hypodermoclysis in multivariable analysis. On study day, the mean length of stay in the unit was significantly longer in the hypodermoclysis group (1447 vs 981 days, p < 0.001). 4. DISCUSSION Our first key finding is the 21% prevalence of hypodermoclysis use among LTC residents. This cross-sectional prevalence is consistent with longitudinal reports showing 6% of residents receiving hypodermoclysis over five weeks (Dasgupta et al.) and 47% over nine months (Arinzon et al.) [ 26 , 27 ]. This figure is consistent with reported dehydration rates in LTC, which average 34% (range 9–89%) [ 5 ]. Moreover, our population presents a high level of frailty (dependence, malnutrition, swallowing disorders, cognitive impairment), all of which are factors potentially associated with an increased risk of dehydration [ 5 ]. In our study, the prevalence of hypodermoclysis varied widely between centers (14% to 36%). We suggest that these variations likely reflect the absence of clear evidence-based guidelines on the practical use of this technique [ 4 , 21 ]. In our study, hypodermoclysis was almost always prescribed for confirmed or suspected dehydration and only rarely because intravenous access was not possible, consistent with Arinzon et al. [ 26 ]. However, our findings contrast with Lowe et Gillon’s hypothesis that the technique is underused, versus intravenous hydration [ 25 ]. A second major finding relates to how hypodermoclysis is administered in practice in LTC. It was most often given in small volumes (typically 500 mL) and for prolonged durations (with a median duration of over three months), sometimes extending over years. This is noteworthy because previous studies have validated hypodermoclysis for larger volumes and shorter periods. In the meta-analysis by Broadhurst et al., the mean daily volume among older adults was 1,340 mL (range 698–1,708 mL) for an average of five days (range 0.25–21 days) [ 22 ]. The mean duration was 15.9 days in Arinzon et al. and 21 days in Dasgupta et al. [ 26 , 27 ]. These findings raise questions about current practice, particularly since ESPEN guidelines emphasize that parenteral hydration should always be considered a medical treatment rather than basic care [ 4 ]. Notably, this raises ethical questions, considering that residents receiving hypodermoclysis had significantly longer lengths of stay in LTC in our study. Regarding the types of solutions used and the predominance of nighttime intermittent administration, our results are consistent with previous studies [ 26 , 27 ]. The infusion sites were also in line with recommendations [ 22 ], though the relatively frequent use of the abdominal route warrants caution, as case reports have described bowel perforation in thin residents [ 23 ] – a relevant concern given the low body weight of our study population. As expected, adverse events related to hypodermoclysis were rare. In the meta-analysis by Danielsen et al., the incidence of adverse effects during subcutaneous hydration was 90 per 1,000 infusions, while serious events — those prolonging hospital stay or requiring additional treatment — occurred in approximately one per 270 infusions [ 23 ]. The daily cost per resident is low, particularly compared with intravenous hydration [ 24 ]. However, given its prolonged use, the cumulative cost for care providers may be substantial. A third important finding concerns the association between hypodermoclysis use and staffing. Unlike in the United States [ 28 ], minimum staff-to-resident ratios in France are not yet legally mandated; they are expected to become enforceable in 2027 following the law adopted on January 29, 2025. This may explain the variability across centers. Nevertheless, staffing levels in participating units were comparable to those reported in prior studies [ 29 , 30 ]. In our analysis, a higher resident-to-nurse ratio was associated with lower use of hypodermoclysis, possibly reflecting reduced time available for infusion procedures, even though hypodermoclysis placement is faster than intravenous access [ 23 ]. This association appeared only in multivariate analysis, perhaps reflecting center-level differences in nurse staffing linked to resident characteristics (e.g., behavioral disorders), since staffing must adapt to resident case mix [ 31 ]. Conversely, a higher resident-to-nursing assistant ratio was associated with greater hypodermoclysis use. This may reflect limited time to assist dependent residents with oral hydration, although prior evidence on this point is mixed [ 12 – 16 ]. Similarly, lower physician staffing was associated with higher hypodermoclysis use, possibly due to reduced time for prescription reassessment. However, we found no supporting literature, and the absence of correlation between the duration of hypodermoclysis and physician staffing does not support this hypothesis. Overall, the association between dehydration and medical or nurse manager staffing has not been explored in the literature, to our knowledge [ 8 – 16 ]. We found no association between hypodermoclysis use and staffing in dietitians or occupational therapists, consistent with Sandoval et al., who found no such association for dehydration [ 14 ]. Likewise, no association was found between hypodermoclysis use and recent staff training, echoing Reed et al., who reported no link between dehydration and staff training level [ 13 ]. It should be noted that reported training in the past year on hydration and swallowing disorders was 37% and 59%, respectively, in our study. The international survey by Cheng et al. showed that most professionals involved in dysphagia and malnutrition management had not received recent structured education, and that care often relies on experience rather than validated tools or standardized protocols [ 32 ]. Nevertheless, as Bunn et al. concluded, staff providing nutrition and hydration care in care homes should have the necessary skills and knowledge, although the specific competencies required remain undefined [ 33 ]. To our knowledge, our study is the first to report on material conditions related to residents’ access to water. Previous literature has primarily focused on the variety of beverages offered [ 17 ]. Our findings indicate that units were highly homogeneous regarding material conditions of water access; therefore, it was not possible to examine their influence on hypodermoclysis practices. Taken together, our results highlight the need to better understand how staffing affects care quality in LTC. Evidence on this association remains mixed, although some categories of nursing staff may be more effective at improving the quality of certain indicators [ 34 ]. In all cases, hydration in older adults remains a key clinical issue in LTC; for which best practices exist, albeit supported by limited evidence [ 17 , 33 ], and which requires interprofessional commitment and collaboration [ 18 , 19 ]. 4.1. Strengths and Limitations This study has several strengths. To our knowledge, this study is the first large-scale investigation of hypodermoclysis practices in LTC over the past two decades. Dasgupta et al. reported its use only in 37 residents in 1999, and Arinzon et al. in 57 residents in 2001–2002 [ 26 , 27 ]. Comparisons with these older studies are limited by changes in the characteristics of LTC residents over decades [ 35 , 36 ]. In particular, residents in Arinzon et al.’s study were younger, and those in Dasgupta et al.’s had lower rates of dementia [ 26 , 27 ]. It reflects real-world practice, providing practical insights into how hypodermoclysis is used in routine care – an aspect not previously reported, and evaluates the multidisciplinary management of dehydration. Finally, to our knowledge, this is the first study to explore how staffing levels and material conditions of water access may shape hydration practices, as we consider these factors to be key contributors to residents’ hydration status. However, some limitations must be acknowledged. First, the cross-sectional design precludes longitudinal assessment and limits our ability to examine temporal associations with unit-level characteristics, which may vary over time. Staff turnover, for example, has been associated with dehydration in previous studies [ 12 ]. Second, data were self-reported by physicians, including indicators such as dehydration, which ideally should be defined using biological criteria in this population [ 3 ]. Third, in this practice survey, we did not investigate the use of the subcutaneous route for purposes other than hydration, nor were we able to assess potential adjustments in hydration prescriptions over time. 5. CONCLUSIONS AND IMPLICATIONS Hypodermoclysis practices in LTC are heterogeneous. It is frequently administered at low infusion volumes and over extended periods, while remaining a safe and low-cost technique. The observed associations between staffing patterns and the likelihood of receiving hypodermoclysis highlight the importance of adequate staffing in supporting hydration management. These findings raise broader questions about care quality in relation to staffing levels. Hydration remains a key clinical issue in LTC and requires sustained interprofessional engagement and collaboration. Declarations Author contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Nicolas DENIAU, Océane LELONG and Anthony MEZIERE. The first draft of the manuscript was written by Nicolas DENIAU and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethical approval This study complied with the Declaration of Helsinki and was approved by an institutional review board (CER APHP.Centre IORG0010044). Funding This research did not receive any funding from agencies in the public, commercial, or not-for-profit sectors. Acknowledgements The authors would like to thank the members of the CLAN central gériatrique AP-HP for their support. Declaration of interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Declaration of generative AI and AI-assisted technologies in the manuscript preparation process During the preparation of this work, the authors used ChatGPT to improve R code and for translation purposes. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article. References Lima Ribeiro SM, Morley JE (2015) Dehydration is difficult to detect and prevent in nursing homes. 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Int J Nurs Stud 122:104036. https://doi.org/10.1016/j.ijnurstu.2021.104036 Barker RO, Hanratty B, Kingston A, Ramsay SE, Matthews FE (2021) Changes in health and functioning of care home residents over two decades: what can we learn from population-based studies? Age Ageing 50:921–927. https://doi.org/10.1093/ageing/afaa227 Matthews FE, Bennett H, Wittenberg R, Jagger C, Dening T, Brayne C et al (2016) Who Lives Where and Does It Matter? Changes in the Health Profiles of Older People Living in Long Term Care and the Community over Two Decades in a High Income Country. PLoS ONE 11:e0161705. https://doi.org/10.1371/journal.pone.0161705 Tables Table 1 to 5 are available in the Supplementary Files section. Supplementary Files TABLESANDFIGURES.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revisions 12 Feb, 2026 Reviewers agreed at journal 16 Jan, 2026 Reviewers invited by journal 14 Jan, 2026 Editor assigned by journal 13 Jan, 2026 First submitted to journal 08 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8558737","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":574470093,"identity":"c93eaed8-885b-498f-be7a-af7924e7862c","order_by":0,"name":"Nicolas DENIAU","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYDACZiB+AGIcACMbBgYJIKeCkJYEhJY0iJYzhGyCaQGCw4S1mLMzP3yQUFPHwHe89+CBn23n5c2lew8wHNyDW4tlM5uxQcKxwwySZ84lHOxtu224c865BIYDz3BrMTjMwyaRwHaAweBGjsEB3rbbjBuADOYPBwhp+VfHYHD/jcHBv23n7EFaGA4Q0pLYxgy0hcfgMG/bgUQitAD9kth3mEfyTI7BYZlzyck7Z+QlHMCr5fzhhw8+fKuT4zt+xvjjmzI72+0SuQcf4NMCAzwIQ4BsIjSg2IukfRSMglEwCkYBCAAAtABcN0/SBzsAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-8097-4184","institution":"Hôpital Corentin Celton: Hopital Corentin Celton","correspondingAuthor":true,"prefix":"","firstName":"Nicolas","middleName":"","lastName":"DENIAU","suffix":""},{"id":574470094,"identity":"0c19b401-6c3e-4b42-beaf-c6688ad5bf2e","order_by":1,"name":"Oceane LELONG","email":"","orcid":"","institution":"Hôpital Corentin Celton: Hopital Corentin 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08:11:11","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":124717,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8558737/v1/396038011f3937af883d784f.html"},{"id":100857669,"identity":"2f16c7b8-49f9-4aa4-8849-e489ea7fe053","added_by":"auto","created_at":"2026-01-22 07:18:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":436619,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8558737/v1/0a79ea75-8a18-4d9c-ad97-f8696f1ad527.pdf"},{"id":100440810,"identity":"1a465115-2f26-482d-8c8d-a9e47c8dc0c4","added_by":"auto","created_at":"2026-01-16 16:38:11","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22053,"visible":true,"origin":"","legend":"","description":"","filename":"TABLESANDFIGURES.docx","url":"https://assets-eu.researchsquare.com/files/rs-8558737/v1/226661caa0c53e979f9c5b75.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003eHypodermoclysis in Long-Term Care: Utilization Patterns and Association With Staffing Levels\u003c/p\u003e","fulltext":[{"header":"KEY SUMMARY POINTS","content":"\u003cp\u003e\u003cstrong\u003eAim:\u003c/strong\u003e Describe hypodermoclysis practices in long-term care and the associated institutional factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings:\u003c/strong\u003e Hypodermoclysis is widely used in long-term care for prolonged, low-volume infusions. Hypodermoclysis practices vary across centers; staffing levels influence use.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMessage:\u003c/strong\u003e Results suggest hypodermoclysis resembles routine care, raising ethical concerns; staffing levels are key to hydration and overall quality of care in long-term care.\u003c/p\u003e"},{"header":"1. INTRODUCTION","content":"\u003cp\u003eDehydration is difficult to detect and prevent among institutionalized older adults [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Because clinical signs of dehydration are unreliable in older adults [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], definitive diagnosis of dehydration relies on biological measures in this population [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Using the diagnostic criterion based on measured osmolality, as recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], the prevalence of dehydration in institutionalized older adults is estimated at 34% (range 3%\u0026ndash;89% across studies) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Dehydration is associated with increased healthcare utilization and healthcare expenditures among older adults [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Older studies estimated the cost of dehydration among older adults in the United States to be approximately one billion dollars [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA commonly cited reason for the high prevalence of dehydration in institutionalized older adults is that they often do not receive adequate fluids during the day, and those unable to drink independently do not receive sufficient assistance [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Several studies have examined the impact of staffing levels on dehydration in institutionalized older adults; however, the level of evidence remains low, and findings are inconsistent [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Shin and Huyn reported that higher staff turnover is associated with a greater risk of dehydration among institutionalized older adults [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Reed et al. suggested that a higher staff-to-resident ratio is associated with a lower risk of dehydration [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], although this finding was not replicated in other studies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Conversely, Namasivayam-MacDonald et al. found that having more staff present in the dining room was associated with an increased risk of dehydration, possibly reflecting a higher number of residents in these settings [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo prevent dehydration in older adults living in residential care, ESPEN recommends implementing multi-component strategies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Based on the systematic review by Bunn et al. \u0026ndash; which found substantial heterogeneity in the interventions studied [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] \u0026ndash; ESPEN recommends that these multi-component strategies include high availability of drinks, varied choice of drinks, the frequent offering of drinks, staff awareness of the need for adequate fluid intake and staff support for drinking [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Subsequent works by Paulis et al. emphasized the importance of interprofessional collaboration in addressing dehydration among institutionalized older adults [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen dehydration is confirmed, ESPEN recommends the use of subcutaneous or intravenous fluids in parallel with encouraging oral fluid intake, in older adults who appear unwell [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This recommendation for hypodermoclysis (subcutaneous fluids infusion) use is primarily based on the older review by Turner et al., which supported the use of dextrose-saline infusions [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. More recently, International Consensus Recommendation Guidelines for Subcutaneous Infusions of Hydration have been published, although they do not specifically target older adults [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEvidence supporting the use of hypodermoclysis remains of low quality but suggests that it is safe and effective for treating mild to moderate dehydration in older adults [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Subcutaneous hydration is also less expensive than intravenous hydration [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Nevertheless, some authors suggest that hypodermoclysis remains underutilized [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Studies investigating its use in long-term care (LTC) settings are generally older and include small sample sizes [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this context, we aimed to examine the use of hypodermoclysis among LTC residents and to explore institutional factors associated with its use, particularly those related to staffing.\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cp\u003eWe conducted a cross-sectional multicenter study based on data collected on a single day (January 21st, 2025). All residents of LTC units affiliated with the Assistance Publique \u0026ndash; H\u0026ocirc;pitaux de Paris (AP-HP) on the index date were included, except those who had explicitly declined the use of their medical data. AP-HP is the largest public hospital network in Europe, providing 1451 LTC beds across 14 hospitals.\u003c/p\u003e \u003cp\u003eSpearheaded by the \u003cem\u003eCLAN central AP-HP\u003c/em\u003e, multicentric Food and Nutrition Committee, geriatricians in charge of each LTC unit were instructed to collect a set of predefined variables for all residents present in unit on the designated study day. These variables included sociodemographic information, relevant clinical data, and specific details related to the use and administration of hypodermoclysis. Geriatricians were instructed to describe the characteristics of their unit, including available staffing and material resources.\u003c/p\u003e \u003cp\u003eThe primary objectives of this study were to determine the prevalence of hypodermoclysis use in LTC settings and to describe the associated clinical practices, including indications, type of fluid administered, prescribed volume, duration of treatment, mode of administration (continuous or intermittent), infusion site, and the use of concomitant oral hydration. The tolerance of hypodermoclysis was also assessed by identifying any reported adverse events potentially related to its administration on the designated study day.\u003c/p\u003e \u003cp\u003eThe secondary objectives were to examine whether unit-level characteristics \u0026ndash; such as staffing (physicians, nurses, nursing assistants, nurse managers, dietitians, occupational therapists, and speech therapists) and material resources (staff training on hydration and swallowing disorders, and access to drinking water for residents) \u0026ndash; were independently associated with the likelihood of receiving hypodermoclysis. Staffing levels were reported either as a resident-to-staff ratio or as full-time equivalents per \u0026ldquo;standard\u0026rdquo; 28-bed unit, as applicable. Costs associated with the use of hypodermoclysis were estimated from the provider perspective.\u003c/p\u003e \u003cp\u003eA statistical plan discussed between clinicians and the statistical analyst was discussed prior to the start of the study. Descriptive statistics summarized resident and unit characteristics, hypodermoclysis use and reported adverse reactions. Continuous variables were presented as medians with interquartile ranges (25th\u0026ndash;75th percentiles), while categorical variables were reported as counts and percentages.\u003c/p\u003e \u003cp\u003eA primary analysis focused on identifying unit-level factors associated with the use of hypodermoclysis. Bivariate analyses were first conducted using Student\u0026rsquo;s t-test or the Mann\u0026ndash;Whitney U test for continuous variables, and the chi-square test or Fisher\u0026rsquo;s exact test for categorical variables, as appropriate. A multivariable logistic regression model was then constructed to examine the association between staffing and the likelihood of receiving hypodermoclysis. Resident-level variables previously identified as potential confounders were included in the model to adjust for differences in clinical indication for hypodermoclysis. For all tests, the alpha-level was defined as 0.05 bilaterally, and analyses were performed with RStudio.\u003c/p\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003eOn the study day, data were collected for 748 residents out of 1451 beds in LTC units, corresponding to a response rate of 52%. The median length of stay in the unit on the day of the study was 685 days (interquartile range: 260\u0026ndash;1348). Residents were predominantly women and had a mean age of 85.66 years. Most were dependent for feeding or hydration (55%). Fifty-three percent had malnutrition, and 49% had swallowing disorders. Nearly all had cognitive impairment (92%). The clinical characteristics of the participants are presented in Table 1. Among the 748 residents, 157 (21%) were receiving hypodermoclysis. The prevalence of hypodermoclysis use varied significantly between centers, ranging from 14% to 36% (p \u0026lt; 0.001). The most common justification for hypodermoclysis was dehydration or risk of dehydration (92%). Among residents not receiving hypodermoclysis, only 6 (1%) were receiving intravenous hydration. Details regarding the presence or absence and indication for hypodermoclysis are presented in Table 2.\u003c/p\u003e\n\u003cp\u003eHypodermoclysis had been used for a median duration of 95 days [IQR: 29\u0026ndash;230 days]. Twenty-two residents had been prescribed hypodermoclysis for more than one year, with the longest prescription lasting 1,777 days. In 10 residents, hypodermoclysis was prescribed continuously for the entire duration of their stay, starting from admission. On average, hypodermoclysis was prescribed for 24% of the stay up to the study day. The most commonly used fluids were dextrose solutions (54%) and dextrose-saline solutions (41%), while only 7% of residents received saline alone. In most cases (69%), the prescribed infusion volume was 500 mL per day. Hypodermoclysis was administered intermittently and overnight in almost all cases. The most common infusion sites were the thigh and abdomen; in 27% of cases, two infusion sites were used simultaneously. In 94% of cases, oral hydration was administered in combination (still: 18%; sparkling: 33%; thickened: 49%). Details regarding the administration of hypodermoclysis are presented in Table 2. Adverse events related to hypodermoclysis were reported in 9% of cases. One serious adverse event (abscess) was reported. Non-serious adverse events included: edema (n = 1), pain (n = 2), erythema (n = 8). The daily cumulative cost of hypodermoclysis (solution and equipment) was USD 259 for all 157 residents. When accounting for the full duration of prescription, the cumulative cost of hypodermoclysis for the 157 residents amounted to USD 54,146.\u003c/p\u003e\n\u003cp\u003eAmong the 27 LTC units, 41% had a \u0026ldquo;standard\u0026rdquo; capacity of 27 or 28 beds. The nurse-to-resident ratio ranged from 1:14 to 1:36, while the nursing assistant-to-resident ratio ranged from 1:5 to 1:10. The mean number of physicians per standard 28-bed unit was 0.58 full-time equivalent. The mean number of dietitians and occupational therapists per standard 28-bed unit was 0.16 full-time equivalent for each profession. Two units reported having no dietitian, and one unit reported having no occupational therapist. Only 37% of units reported access to speech therapist consultation, and 19% reported access to speech therapist rehabilitation. Reported training during the past year on hydration or swallowing disorders was 37% et 59%, respectively. All units reported access to sparkling or thickened water. In 57% of units, a water fountain was accessible to residents, and only two units reported not having a communal room for lunch. Unit characteristics are presented in Table 3.\u003c/p\u003e\n\u003cp\u003eIn univariate analysis, the use of hypodermoclysis was associated with a higher resident-to-nursing assistant ratio and lower physician staffing (Table 4). Conversely, the resident-to-nurse ratio, staffing levels in nurse managers, dietitians, occupational therapists, or speech therapists were not associated with the use of hypodermoclysis, nor were staff training or material conditions. In the multivariate analysis \u0026ndash; adjusted for age, sex, weight, feeding or hydration dependency, malnutrition, swallowing disorders, and cognitive impairment \u0026ndash; factors independently associated with the use of hypodermoclysis included the resident-to-nurse ratio (OR = 0.73), the resident-to-nursing assistant ratio (OR = 1.75), and the physician staffing (OR = 0.70) (Table 5). There was no correlation between the duration of hypodermoclysis prescription (as a proportion of the length of stay) and physician staffing (p = 0.633). Staffing levels in nurse managers, dietitians, and occupational therapists remained unassociated with the use of hypodermoclysis in multivariable analysis. On study day, the mean length of stay in the unit was significantly longer in the hypodermoclysis group (1447 vs 981 days, p \u0026lt; 0.001).\u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eOur first key finding is the 21% prevalence of hypodermoclysis use among LTC residents. This cross-sectional prevalence is consistent with longitudinal reports showing 6% of residents receiving hypodermoclysis over five weeks (Dasgupta et al.) and 47% over nine months (Arinzon et al.) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This figure is consistent with reported dehydration rates in LTC, which average 34% (range 9\u0026ndash;89%) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Moreover, our population presents a high level of frailty (dependence, malnutrition, swallowing disorders, cognitive impairment), all of which are factors potentially associated with an increased risk of dehydration [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In our study, the prevalence of hypodermoclysis varied widely between centers (14% to 36%). We suggest that these variations likely reflect the absence of clear evidence-based guidelines on the practical use of this technique [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In our study, hypodermoclysis was almost always prescribed for confirmed or suspected dehydration and only rarely because intravenous access was not possible, consistent with Arinzon et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, our findings contrast with Lowe et Gillon\u0026rsquo;s hypothesis that the technique is underused, versus intravenous hydration [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA second major finding relates to how hypodermoclysis is administered in practice in LTC. It was most often given in small volumes (typically 500 mL) and for prolonged durations (with a median duration of over three months), sometimes extending over years. This is noteworthy because previous studies have validated hypodermoclysis for larger volumes and shorter periods. In the meta-analysis by Broadhurst et al., the mean daily volume among older adults was 1,340 mL (range 698\u0026ndash;1,708 mL) for an average of five days (range 0.25\u0026ndash;21 days) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The mean duration was 15.9 days in Arinzon et al. and 21 days in Dasgupta et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. These findings raise questions about current practice, particularly since ESPEN guidelines emphasize that parenteral hydration should always be considered a medical treatment rather than basic care [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Notably, this raises ethical questions, considering that residents receiving hypodermoclysis had significantly longer lengths of stay in LTC in our study. Regarding the types of solutions used and the predominance of nighttime intermittent administration, our results are consistent with previous studies [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The infusion sites were also in line with recommendations [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], though the relatively frequent use of the abdominal route warrants caution, as case reports have described bowel perforation in thin residents [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] \u0026ndash; a relevant concern given the low body weight of our study population.\u003c/p\u003e \u003cp\u003eAs expected, adverse events related to hypodermoclysis were rare. In the meta-analysis by Danielsen et al., the incidence of adverse effects during subcutaneous hydration was 90 per 1,000 infusions, while serious events \u0026mdash; those prolonging hospital stay or requiring additional treatment \u0026mdash; occurred in approximately one per 270 infusions [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The daily cost per resident is low, particularly compared with intravenous hydration [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, given its prolonged use, the cumulative cost for care providers may be substantial.\u003c/p\u003e \u003cp\u003eA third important finding concerns the association between hypodermoclysis use and staffing. Unlike in the United States [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], minimum staff-to-resident ratios in France are not yet legally mandated; they are expected to become enforceable in 2027 following the law adopted on January 29, 2025. This may explain the variability across centers. Nevertheless, staffing levels in participating units were comparable to those reported in prior studies [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In our analysis, a higher resident-to-nurse ratio was associated with lower use of hypodermoclysis, possibly reflecting reduced time available for infusion procedures, even though hypodermoclysis placement is faster than intravenous access [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This association appeared only in multivariate analysis, perhaps reflecting center-level differences in nurse staffing linked to resident characteristics (e.g., behavioral disorders), since staffing must adapt to resident case mix [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Conversely, a higher resident-to-nursing assistant ratio was associated with greater hypodermoclysis use. This may reflect limited time to assist dependent residents with oral hydration, although prior evidence on this point is mixed [\u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Similarly, lower physician staffing was associated with higher hypodermoclysis use, possibly due to reduced time for prescription reassessment. However, we found no supporting literature, and the absence of correlation between the duration of hypodermoclysis and physician staffing does not support this hypothesis. Overall, the association between dehydration and medical or nurse manager staffing has not been explored in the literature, to our knowledge [\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14 CR15\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. We found no association between hypodermoclysis use and staffing in dietitians or occupational therapists, consistent with Sandoval et al., who found no such association for dehydration [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Likewise, no association was found between hypodermoclysis use and recent staff training, echoing Reed et al., who reported no link between dehydration and staff training level [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It should be noted that reported training in the past year on hydration and swallowing disorders was 37% and 59%, respectively, in our study. The international survey by Cheng et al. showed that most professionals involved in dysphagia and malnutrition management had not received recent structured education, and that care often relies on experience rather than validated tools or standardized protocols [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Nevertheless, as Bunn et al. concluded, staff providing nutrition and hydration care in care homes should have the necessary skills and knowledge, although the specific competencies required remain undefined [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. To our knowledge, our study is the first to report on material conditions related to residents\u0026rsquo; access to water. Previous literature has primarily focused on the variety of beverages offered [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Our findings indicate that units were highly homogeneous regarding material conditions of water access; therefore, it was not possible to examine their influence on hypodermoclysis practices.\u003c/p\u003e \u003cp\u003eTaken together, our results highlight the need to better understand how staffing affects care quality in LTC. Evidence on this association remains mixed, although some categories of nursing staff may be more effective at improving the quality of certain indicators [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In all cases, hydration in older adults remains a key clinical issue in LTC; for which best practices exist, albeit supported by limited evidence [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], and which requires interprofessional commitment and collaboration [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003e4.1. Strengths and Limitations\u003c/h3\u003e\n\u003cp\u003eThis study has several strengths. To our knowledge, this study is the first large-scale investigation of hypodermoclysis practices in LTC over the past two decades. Dasgupta et al. reported its use only in 37 residents in 1999, and Arinzon et al. in 57 residents in 2001\u0026ndash;2002 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Comparisons with these older studies are limited by changes in the characteristics of LTC residents over decades [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In particular, residents in Arinzon et al.\u0026rsquo;s study were younger, and those in Dasgupta et al.\u0026rsquo;s had lower rates of dementia [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. It reflects real-world practice, providing practical insights into how hypodermoclysis is used in routine care \u0026ndash; an aspect not previously reported, and evaluates the multidisciplinary management of dehydration. Finally, to our knowledge, this is the first study to explore how staffing levels and material conditions of water access may shape hydration practices, as we consider these factors to be key contributors to residents\u0026rsquo; hydration status. However, some limitations must be acknowledged. First, the cross-sectional design precludes longitudinal assessment and limits our ability to examine temporal associations with unit-level characteristics, which may vary over time. Staff turnover, for example, has been associated with dehydration in previous studies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Second, data were self-reported by physicians, including indicators such as dehydration, which ideally should be defined using biological criteria in this population [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Third, in this practice survey, we did not investigate the use of the subcutaneous route for purposes other than hydration, nor were we able to assess potential adjustments in hydration prescriptions over time.\u003c/p\u003e"},{"header":"5. CONCLUSIONS AND IMPLICATIONS","content":"\u003cp\u003eHypodermoclysis practices in LTC are heterogeneous. It is frequently administered at low infusion volumes and over extended periods, while remaining a safe and low-cost technique. The observed associations between staffing patterns and the likelihood of receiving hypodermoclysis highlight the importance of adequate staffing in supporting hydration management. These findings raise broader questions about care quality in relation to staffing levels. Hydration remains a key clinical issue in LTC and requires sustained interprofessional engagement and collaboration.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Nicolas DENIAU, Oc\u0026eacute;ane LELONG and Anthony MEZIERE. The first draft of the manuscript was written by Nicolas DENIAU and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study complied with the Declaration of Helsinki and was approved by an institutional review board (CER APHP.Centre IORG0010044).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any funding from agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the members of the CLAN central g\u0026eacute;riatrique AP-HP for their support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of generative AI and AI-assisted technologies in the manuscript preparation process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this work, the authors used ChatGPT to improve R code and for translation purposes. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLima Ribeiro SM, Morley JE (2015) Dehydration is difficult to detect and prevent in nursing homes. J Am Med Dir Assoc 16:175\u0026ndash;176. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jamda.2014.12.012\u003c/span\u003e\u003cspan address=\"10.1016/j.jamda.2014.12.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHooper L, Abdelhamid A, Attreed NJ, Campbell WW, Channell AM, Chassagne P et al (2015) Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people. 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PLoS ONE 11:e0161705. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0161705\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0161705\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-geriatric-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"EGEM","sideBox":"Learn more about [European Geriatric Medicine](https://www.springer.com/journal/41999)","snPcode":"41999","submissionUrl":"https://www.editorialmanager.com/egem/default2.aspx","title":"European Geriatric Medicine","twitterHandle":"","acdcEnabled":false,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Hypodermoclysis, Dehydration, Aged, Long-term care, Personnel staffing and scheduling, Quality of health care","lastPublishedDoi":"10.21203/rs.3.rs-8558737/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8558737/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePURPOSE\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo determine the prevalence of hypodermoclysis use in long-term care (LTC) settings, describe associated clinical practices, and examine association between hypodermoclysis use and unit-level characteristics.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMETHODS\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCross-sectional multicenter study based on data collected on a single day. Resident data from LTC units were collected by the supervising geriatricians of 27 LTC units affiliated with the Assistance Publique\u0026ndash;H\u0026ocirc;pitaux de Paris (AP-HP). Descriptive statistics summarized hypodermoclysis practices. A multivariable logistic regression was performed to assess the association between staffing levels and the likelihood of receiving hypodermoclysis.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRESULTS\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAmong 748 residents, 21% were receiving hypodermoclysis, with prevalence varying significatively across centers (14%\u0026ndash;36%). Hypodermoclysis has been prescribed for a median duration of 95 days on the study day. It most commonly involved dextrose solution, prescribed at 500 mL per day. Factors independently associated with hypodermoclysis use included the resident-to-nurse ratio (OR\u0026thinsp;=\u0026thinsp;0.73), the resident-to\u0026ndash;nursing assistant ratio (OR\u0026thinsp;=\u0026thinsp;1.75), and physician staffing (OR\u0026thinsp;=\u0026thinsp;0.70).\u003c/p\u003e\u003cp\u003e\u003cb\u003eCONCLUSION\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFindings reveal heterogeneous use of hypodermoclysis in LTC, often at low volumes and over prolonged periods. Given the association between staffing levels and hypodermoclysis use, strengthened interprofessional engagement and collaboration may be needed to optimize hydration practices.\u003c/p\u003e","manuscriptTitle":"Hypodermoclysis in Long-Term Care: Utilization Patterns and Association With Staffing Levels","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 16:38:02","doi":"10.21203/rs.3.rs-8558737/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revisions","date":"2026-02-12T07:42:09+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2026-01-16T10:09:36+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-14T10:35:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-13T05:48:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Geriatric Medicine","date":"2026-01-09T03:48:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-geriatric-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"EGEM","sideBox":"Learn more about [European Geriatric Medicine](https://www.springer.com/journal/41999)","snPcode":"41999","submissionUrl":"https://www.editorialmanager.com/egem/default2.aspx","title":"European Geriatric Medicine","twitterHandle":"","acdcEnabled":false,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"bfe5dad0-de87-45fe-a900-77d2e8747bd5","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T01:37:48+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 16:38:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8558737","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8558737","identity":"rs-8558737","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}