Dietitian Blog, Long-Term Care, MNT Guidelines | Apr 26 2022

Dehydration in the elderly: Are we doing enough?

Two elderly women drinking beverages to prevent dehydration

For elderly individuals, dehydration can lead to significant health issues, including urinary tract infections, kidney failure, falls, and hospitalizations. Elderly populations are at higher risk for dehydration for a myriad of reasons. Despite this, many seniors are drinking less fluid than they need. Knowing dehydration has such a significant impact on health outcomes, are dietitians focused on making sure our patients and residents are adequately hydrated? 

Acute vs chronic dehydration 

Adequate hydration provides our bodies with the substance needed for metabolism, circulation, temperature control, and skin health, among other functions. Inadequate hydration issues, however, are not all the same. Acute dehydration results from an excessive water loss caused by an acute illness, such as diarrhea, vomiting, or fever. These conditions can lead to moderate to severe dehydration. 

Chronic dehydration, on the other hand, is insidious and develops after a longer period of inadequate fluid intake. It is commonly caused by a beverage intake inadequate to meet the fluid losses through urine, feces, breath, or sweat. Clinical assessment signs like skin turgor, urine color and volume, or heart rate may not be reliable in chronic dehydration. The signs may be misleading and caused by other conditions common in older adults. Is that dry mouth indicative of a low fluid intake or a side effect of a medication? 

Economic cost 

Dehydration is a multi-billion-dollar problem. The United States’ healthcare costs increase year over year with what could be preventable hospitalizations and procedures. According to The Joint Commission, total costs for the treatment of pressure injuries alone, a common risk associated with dehydration, is estimated at $11 billion annually. In this era of correlating care with improved health outcomes and reduced costs, it is critical that we focus on the low hanging fruit.  

Adequate hydration may be often overlooked as a significant issue that is essential for ongoing good health. While there is significant overlap with the diagnosis of malnutrition, adding more calories is not always the answer. Health outcomes can be improved and hospital expenditures reduced if health care providers routinely monitor individuals susceptible to dehydration and address the problems swiftly. 

The importance of preventing chronic dehydration  

Something as small as not drinking enough fluid can cause significant problems in older adults.  Dehydration increases the risk for: 

  • Poor recovery from illness 
  • Kidney failure, kidney stones, urinary tract infections 
  • Falls and fractures 
  • Pressure injuries 

 Not meeting the body’s fluid needs has been shown to increase cognitive impairment and dementia. The increasing confusion reduces the ability for self-care, including something as simple as obtaining a drink. An improved quality of life could be one cup of juice away. 

Older adults are at high risk 

Changes and behaviors associated with aging increase the risk for chronically inadequate fluid intake. Symptoms can include headaches, fatigue, general malaise, and increased confusion. 

Physiological changes like reduced thirst sensation, lower ability to concentrate urine, as well as the diminished muscle mass of sarcopenia result in a smaller fluid reserve. Medications may also play a role in fluid loss with the increased use of laxatives and diuretics. 

Physical limitations play a significant role in this process. Older adults may not have the mobility to get a drink and less strength to pour and hold a cup. Studies have shown increased fluid intake just by changing to lightweight cups with large handles. Also, those with urinary incontinence may voluntarily restrict their fluid intake out of fear of not making it to the bathroom on time. Dementia may decrease the ability to just ask for a drink.     

Daily fluid intake recommendations  

The Institute of Medicine recommendations for daily fluid intake seven to eight cups per day. Larger people require more fluid. Summer heat and exercise as well as fever, diarrhea, vomiting all increase needs. On the other hand, specific conditions such as heart and kidney failure may require a fluid restriction. Studies have shown that adults living at home are less likely to have inadequate fluid intake, while those living in long-term care facilities are more likely and older hospitalized adults are at highest risk of inadequate fluid intake. Also, pay attention to seniors on thickened liquids or oral nutritional supplements. Both of these groups have been shown to be at high risk of inadequate fluid intake.   

In 2019, the European Society for Clinical Nutrition and Metabolism (ESPEN) developed evidence-based guidelines on nutrition and hydration in geriatrics with recommendations for low-intake dehydration. The interventions listed below are based on these recommendations. 

Interventions to increase fluid intake 

  • Work with the seniors to develop a beverage menu of preferred drinks of their choosing.  Include teas, water, juice, smoothies, non-alcoholic beer or wine, if appropriate. It is more important to drink than what they are drinking. 
  • Make sure beverages are available and accessible. 
  • Offer drinks frequently. Small amounts frequently are often better accepted than a large amount in one sitting. Set dedicated drink times. Offer beverages before breakfast and midafternoon. Have afternoon tea or Happy Hours. 
  • Emphasize to caregivers and staff of the need for adequate fluid intake. It is important that everyone is on the same page. 
  • Make sure staff is available to assist and support drinking fluids. This is particularly important for those seniors with limited physical ability. 
  • Staff need to be available to take older adults to the toilet quickly and when they need it.  Seniors will self-restrict fluids to prevent being embarrassed with an “accident.” 
  • Check out the drinking glasses. Keep them lightweight and easy to handle. 

Consider all older persons we care for to be at risk for dehydration. Work to customize interventions to meet the situation and person. Small changes can have a big impact. Cheers! 

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“Association between Dehydration and Falls,” I Hamrick, MD. et al, Mayo Foundation of Medical Education and Research, 2020. 
“Impending low intake Dehydration at Admission to a Geriatric Ward – Prevalence and Correlates in a Cross-Sectional Study,” Zyta Beata Wojszel. Nutrients 2020, 12, 298. 
“Methods of Assessment of Hydration Status and their Usefulness in Detecting Dehydration in the Elderly,” Aggie Bak, et al. Current Research in Nutrition and Food Science. Vol 5 No 0(2), 2017. 
Narrative Review of low-intake Dehydration in Older Adults,” Anne Marie Beck, et al. Nutrients Sept 2021. 
“Chronic Dehydration in Nursing Home Residents,” Masaoki Nagae, et al. Nutrients, October 2020. 
“The association between hydration status and cognitive function among free-living elderly volunteers,” Agata Bialecka-Debek and Barbara Pietruszka. Aging Clinical and Experimental Research (2019) 31:695-703 
“ESPEN guideline on clinical nutrition and hydration in geriatrics,” Dorothee Volkert, et al. Clinical Nutrition. 38 (2019) 10-47.
Patricia Nicholas, MS, RD, CSG, CDN

About Patricia Nicholas

Patricia Nicholas, MS, RD, CSG, CDN is passionate about improving life for seniors in the community, inpatient, home care and long-term care settings. She stresses healthy food over medications. Along with her patient care experience, she has a background in classroom instruction and clinical and food service management.

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