Dehydration is a serious problem for older adults. It occurs as both a precipitating and comorbid condition leading to unnecessary hospitalizations for older adults. In 2008, 9% of all hospital admissions for adults older than 65 were with dehydration as a secondary diagnosis; of the more than 300,000 admissions for dehydration as a primary diagnosis, 50% occurred in adults older than 65 at a cost of more than $2 billion (Agency for Healthcare Research and Quality [AHRQ], 2008). Dehydration has been associated with longer hospital stays for rehabilitation (Mukand, Cai, Zielinski, Danish, & Berman, 2003) and for hospital readmissions (Gordon, An, Hayward, & Williams, 1998) at excess cost (Xiao, Barber, & Campbell, 2004). For Medicare patients hospitalized with a diagnosis of dehydration, 18% died within 30 days and approximately half died within 1 year of diagnosis (Warren et al., 1994). In addition, dehydration has been designated as one of 13 ambulatory-care sensitive conditions (AHRQ, 2007). An ambulatory-care sensitive condition is a health problem that is thought to be best treated by primary care practitioners. Even in healthy community-dwelling older adults, mild dehydration has been found to affect physical performance and cognitive processing (Ainslie et al., 2002).
Given the serious consequences of dehydration for older adults, gerontological nurses and health care teams must make hydration management a priority in the care of this population. This article is a summary of the evidence-based practice guideline Hydration Management (Mentes & Kang, 2011), which is available for purchase from The University of Iowa Hartford Center of Geriatric Nursing Excellence at http://www.nursing.uiowa.edu/Hartford/nurse/ebp.htm. The purpose of the guideline is to help health care providers in all settings determine adequate oral fluid intake for older adults and to use strategies that will maintain hydration (Mentes & Kang, 2011). Use of the guideline will help prevent dehydration and associated conditions, such as acute confusion/delirium (Foreman, 1989; Mentes, Culp, Maas, & Rantz, 1999; O’Keeffe & Lavan, 1996), adverse drug reactions (Doucet et al., 2002), infections (Beaujean et al., 1997; Masotti et al., 2000), and increased mortality associated with bladder cancer, coronary heart disease, and stroke (Chan, Knutsen, Blix, Lee, & Fraser, 2002; Kelly et al., 2004; Michaud et al., 1999; Rasouli, Kiasari, & Arab, 2008; Wakefield, Mentes, Holman, & Culp, 2009; Warren et al., 1994). The focus of hydration management is to prevent dehydration through careful assessment, identification of older adults at risk for hydration problems, and implementation of individualized nursing interventions based on a risk profile. The guideline does not include interventions for acute or emergent rehydration of elderly individuals.
Hydration management is the promotion of adequate fluid balance, which prevents complications resulting from abnormal or undesired fluid levels (See Fluid Management nursing intervention in Bulechek, Butcher, & McCloskey-Dochterman, 2008, p. 370).
Terms associated with dehydration are categorized in one of three ways: (a) sodium concentration (hypernatremic dehydration), (b) the fluid compartment affected (intracellular dehydration), or (c) the tonicity or active osmoles of the fluid (e.g., hypertonic dehydration).
For purposes of this article, tonicity will be used to define the types of dehydration and to discuss hydration management for older adults (Weinberg & Minaker, 1995).
Hypotonic dehydration, also known as extracellular fluid volume depletion, is depletion in both sodium and water with greater losses of sodium than water, resulting in extracellular fluid loss (Leaf, 1984; Mange et al., 1997; Silver, 1990). Causes of hypotonic dehydration include overuse of diuretic agents, chronic salt wasting renal disease, and decreased intake of both salt and water. Circulation is decreased in hypotonic dehydration (Leaf, 1984; Silver, 1990).
This type of dehydration, also known as isotonic fluid volume depletion, is a balanced depletion of water and sodium causing extracellular fluid loss. Causes of isotonic dehydration are vomiting, diarrhea, and the osmotic diuresis of glucose.
This type of dehydration, also known as intracellular dehydration and hypernatremic dehydration, is depletion in total body water content due to pathologic fluid losses, diminished water intake, or a combination of both (Gross et al., 1992). It results in hypernatremia in the extracellular fluid compartment, which draws water from the intracellular fluids. The water loss is shared by all body fluid compartments, and relatively little reduction in extracellular fluids occurs. Thus, circulation is not compromised unless the loss is large (Leaf, 1984; Mange et al., 1997).
Of the three types of dehydration, hypertonic dehydration, characterized by decreased intake of fluids, is the most common type in older adults because of a variety of age-related changes and disease factors.
Risk Factors for Dehydration
Older adults are at increased risk for dehydration because of age-related physiological changes and personal health and demographic factors (Table 1). In addition, certain older adults are at increased risk if they have specific health problems such as chronic mental illness, stroke, surgical intervention, or are at the end of life.
Table 1: Dehydration Risk Factors
Chronic Mental Illness
Special consideration should be given to older adults with chronic mental illness (e.g., schizophrenia, bipolar disorder, obsessive-compulsive disorder), as they may be at risk for both over- and under-hydration. Antipsychotic medications may blunt the thirst response and put older adults at increased risk in hot weather for dehydration and heat stroke (Batscha, 1997). In addition, even small increases in antipsychotic medications may predispose older adults to neuroleptic malignant syndrome, of which hyperthermia and dehydration are prominent features (Bristow & Kohen, 1996; Jacobs, 1996; Sachdev, Mason, & Hadzi-Pavlovic, 1997). In these individuals, risks for overhydration stem from a combination of the drying side effects of prescribed psychotropic medications and the individual’s compulsive behaviors, which can result in excessive fluid intake (Cosgray, Davidhizar, Giger, & Kreisl, 1993).
Increasing evidence demonstrates that dehydration may play an important part in contributing to early cerebral ischemia (Rodriguez et al., 2009) and delaying recovery from stroke (or preventing early recovery from stroke) (Kelly et al., 2004). In fact, Kelly et al. (2004) found that dehydration in stroke patients was hospital acquired and led to poorer outcomes for recovering stroke patients. Dehydration, signified by increased serum osmolality, led to a nearly three- to five-fold increase in the risk of hospitalized stroke patients acquiring a venous thromboembolism. Another sequela of stroke that can cause dehydration is dysphagia, not only from the difficulty of swallowing but also from the poor palatability of the thickened fluids offered to patients to prevent aspiration (Whelan, 2001). Thus, carefully and continuously monitoring hospitalized older adults for dehydration who are recovering from stroke is imperative.
Prolonged withholding of fluids and food (NPO status) prior to elective surgery has been linked to increased risk of dehydration and adverse effects such as thirst, hunger, irritability, headache, hypovolemia, and hypoglycemia (Smith, Vallance, & Slater, 1997; Yogendran, Asokumar, Cheng, & Chung, 1995). Crenshaw and Winslow (2002) found that despite the formulation of national guidelines developed by the American Society of Anesthesiologist Task Force on Preoperative Fasting (1999), patients were still being instructed to fast longer than necessary before surgery. In fact, patients may safely consume clear liquids up to 2 hours before elective surgery using general anesthesia, regional anesthesia, or sedation anesthesia (American Society of Anesthesiologist Task Force on Preoperative Fasting, 1999).
Maintaining or withholding fluids at the end of life remains a controversial issue. Proponents suggest that dehydration in terminally ill patients is not painful and lessens other noxious symptoms of terminal illness, such as excessive pulmonary secretions, nausea, edema, and pain (dehydration acts as a natural anesthetic) (Fainsinger & Bruera, 1997). Some suggest additional benefits are the decreased need to get up to use the toilet or use bed pans or incontinence briefs, which can be difficult or painful at the end of life (Mion & O’Connell, 2003). Opponents to this position argue that associated symptoms of dehydration, such as acute confusion/delirium, are stressful and reduce the quality of life for terminally ill older adults (Bruera, Belzile, Watanabe, & Fainsinger, 1996).
Most research that has been conducted with terminally ill cancer patients has examined discomforts of dehydration including thirst, dry mouth, and agitated delirium. However, studies have not demonstrated a link between biochemical markers of dehydration and various symptoms in terminally ill patients (Burge, 1993; Ellershaw, Sutliffe, & Saunders, 1995; Morita, Tei, Tsunoda, Inoue, & Chihara, 2001). Factors that have been found to influence the uncomfortable dehydration-like symptoms that accompany the end of life are use and dosage of opiate agents, type and location of cancer, hyperosmolality, stomatitis, and oral breathing (Morita et al., 2001).
Some evidence supports use of hydration to relieve problematic symptoms at the end of life. For example, small amounts of fluids delivered subcutaneously via hypodermoclysis plus opioid rotation was effective in decreasing delirium and antipsychotic agent use and did not cause edema in terminally ill patients (Bruera et al., 1996). A pilot study that tested parenteral hydration in terminally ill cancer patients led to statistically significant decreases in hallucination, myoclonus, fatigue, and sedation (Bruera et al., 2005). Research also suggests artificial hydration does not prolong life (Bruera et al., 2005; Meier, Ahronheim, Morris, Baskin-Lyons, & Morrison, 2001; Mitchell, Kiely, & Lipsitz, 1997).
Given the evidence, recommendations state that maintaining or withholding fluids at the end of life is an individual decision that should be based on the etiology of illness, use of medications, presence of delirium, and patient and family preferences (Fainsinger & Bruera, 1997; Morita et al., 2001; Schmidlin, 2008). Schmidlin (2008) recommends early discussions with patients and family regarding their wishes, as well as educating patients on the current knowledge about artificial hydration so that proper, patient-centered care is provided.
The care setting can affect risk for dehydration, with hospitalized older adults at risk because they are often frail or incapacitated and cannot drink independently, and nursing home residents are at risk because of multiple comorbid conditions, polypharmacy, depression, and functional inability to procure or drink fluids independently (Mentes, Chang, & Morris, 2006). Community-dwelling older adults can be at increased risk for dehydration due to isolation and the tendency to decrease fluid intake as one ages (Popkin, 2010; Zizza, Ellison, & Wernette, 2009).
A hydration intervention should begin with a thorough assessment of the older adult. A comprehensive assessment consists of the following: health history, including pertinent diagnoses and medications; physical assessment, including vital signs, weight, and physical signs of hydration problems such as dry mouth; laboratory tests that may indicate hydration problems (Table 2 and Table 3); functional assessments, including ability to care for self, presence of depression, or cognitive impairment; and personal hydration habits. Once the assessment is complete, the Dehydration Risk Appraisal Checklist can be used to quantify risk; risk for dehydration increases as more items are checked (Figure 1).
Table 2: Relative Strength of Signs of Dehydration In Older Adults
Table 3: Approximate Ranges of Laboratory Tests for Hydration Status
Figure 1. Dehydration Risk Appraisal Checklist.Note. Adapted from text in Mentes and Wang (2011). MMSE = Mini-Mental State Examination; GDS = Geriatric Depression Scale; ADLs = activities of daily living; BMI = body mass index.
Another way to conceptualize risk for dehydration is to classify oral hydration habits (Figure 2). In a direct observational study of 35 older adults, Mentes (2006) identified different strategies to prevent dehydration in nursing home residents based on drinking habits. The “Can Drink” group had a 14% risk of dehydration (2 of 14 individuals) and included independent adults and those who forget to drink. The “Can’t Drink” group had a 38% risk (5 of 13 individuals) and included people with swallowing limitations and those who were physically dependent. The “Won’t Drink” group had a 57% risk (4 of 7 individuals) and included those who liked to sip and those who refused to drink because they feared the embarrassment of incontinence. Only one person comprised the “End of Life” group. More than one third of the participants developed dehydration, demonstrating the increased risk for all nursing home residents regardless of drinking habits. Figure 2 details the different strategic measures suggested by Mentes (2006) based on the residents’ drinking habits. The tailored guide can be helpful in maximizing hydration for individual older adults.
Figure 2. Types of hydration problems and suggested strategies. From Mentes, J.C. (2006). A typology of oral hydration problems exhibited by frail nursing home residents. Journal of Gerontological Nursing, 32(1), 13–19. Copyright 2006 by SLACK Incorporated. Reprinted with permission.
Following assessment, hydration management continues with determining the appropriate amount of fluid to be consumed daily. Current recommendations for fluid intake have been established by the Institute of Medicine (IOM), which is referred to as adequate intake. IOM (2005) recommendations are 3.7 liters per day for men and 2.7 liters per day for women 70 and older. However, this estimate is for older adults who are active and are not frail or sedentary. For older adults who are institutionalized, the following two recommendations have been studied the most and have resulted in similar recommended amounts:
- 100 mL/kg for first 10 kg of weight, 50 mL/kg for next 10 kg, and 15 mL for remaining kg (Skipper, 1993). For example, a 70-kg (154 lb) individual would have a fluid goal of 2,250 mL per day; a 50-kg (110 lb) individual would have a fluid goal of 1,950 mL per day.
- 75% of 1,600 mL/m2 of body surface per day (Gaspar, 2011). For example, a 70-kg individual who is 170 cm tall would have a fluid goal of 2,180 mL per day; a 50-kg individual who is 155 cm tall would have a fluid goal of 1,780 mL per day.
Gaspar (2011) simplified the calculation of the second standard above by developing a nomogram that is based on height and weight to help determine adequate fluid intake in sedentary, institutionalized adults.
Once the fluid amount has been determined, it is recommended that fluids be consumed throughout the day (Hodgkinson, Evans, & Wood, 2003). To help older adults achieve this, they must either be educated about how much fluid is considered adequate, or they should be provided with the fluids in that adequate amount (Mentes, 2006). Several strategies can be used to encourage intake such as providing palatable and preferred beverages (Simmons, Alessi, & Schnelle, 2001; Zembrzuski, 1997), limiting alcoholic and carbonated beverages and providing a standard amount of fluid with medications (Mentes & Culp, 2003). Preliminary evidence indicates that no untoward effects on fluid balance occur for regular users of caffeinated beverages; therefore, they may be of an adequate fluid intake (Martof & Knox, 1997; Maughan & Griffin, 2003).
For at risk individuals, several interventions are recommended:
- Fluid rounds mid-morning and late afternoon, in which the caregiver provides additional fluids (Robinson & Rosher, 2002).
- Provide 2 to 8 oz glasses of fluid in the morning and evening (Robinson & Rosher, 2002).
- “Happy hours” in the afternoon, when older adults can gather together for additional fluids and socialization (Mentes, Chang, & Morris, 2006).
- “Tea time” in the afternoon, when older adults come together for fluids, nourishment, and socialization (Mentes & Culp, 2003).
- Use of modified fluid containers based on the individual’s intake behaviors (e.g., ability to hold cup, swallow) (Mentes & Culp, 2003).
- Offer a variety of fluids and encourage ongoing intake throughout the day for cognitively impaired older adults. Offer fluids that the individuals prefer (Mentes, Chang, & Morris, 2006; Simmons et al., 2001).
- Offer encouragement to drink (Mentes, Chang, & Morris, 2006).
- Encourage family involvement and support (Mentes, Chang, & Morris, 2006).
- Coordinate staff communication about hydration such as certified nursing assistant handoff reports (Mentes, Chang, & Morris, 2006).
Evaluation of hydration interventions should occur on a regular basis. Although serum osmolality is the best indicator of dehydration in older adults, evaluating hydration status and impending hydration problems is best accomplished by looking at several indicators such as oral hydration habits and urine parameters, including urine color and specific gravity (Hooper et al., 2012; Mentes, 2006). A urine color chart developed by Armstrong et al. (1994) has been used in many settings to evaluate hydration status when other more intrusive evaluations are not available.
Conclusion and Implications for Gerontological Nursing Practice
Adequate hydration is a basic human need. As individuals age, their daily fluid intake tends to decrease. Adults 85 and older, on average, drink the least amount of fluid at 850 cc per day (Zizza et al., 2009). Nurses should be aware that older adults are at increased risk for hydration problems, specifically dehydration, and should carefully assess the older individuals for whom they provide care. Older adults are a vulnerable population, and seemingly simple disruptions in fluid and food intake can precipitate an episode of dehydration. After establishing risk, nurses can provide the necessary education about fluid intake or offer assistance with encouraging intake by using some of the interventions discussed in the Hydration Management guideline (Mentes & Kang, 2011). Nurses can also be proactive by advocating for shorter fasting times for older patients who are awaiting surgery or diagnostic tests, or ensuring that food and fluids are available after normal service hours (e.g., in the emergency department). In addition, nurses can carefully monitor intake when elderly clients are not feeling well, as several missed meals can contribute to hydration problems. Through use of the Hydration Management evidence-based practice guideline, dehydration episodes in older adults can be decreased and unnecessary emergency department visits and hospitalizations may be avoided.
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Dehydration Risk Factors
|Age-Related Physiological Changes||Sources|
|Altered thirst perception in older men||Farrell et al., 2008; Kenny & Chui, 2001; Phillips, Bretherton, Johnston, & Gray, 1991|
|Reduced total body water as a portion of body weight related to body composition changes (e.g., higher proportion of fat to muscle)||Bossingham, Carnell, & Campbell, 2005|
|Impaired renal conservation of water||Lindeman, Tobin, & Shock, 1985; Rowe, Shock, & DeFronzo, 1976|
|Decreased effectiveness of vasopressin||Faull, Holmes, & Baylis, 1993; O’Neill, Duggan, & Davies, 1997; Phillips et al., 1993|
|Increased prevalence of multiple chronic diseases||Morgan, Masterson, Fahlman, Topp, & Boardley, 2003|
|Poor tolerance for hot weather||Josseran et al., 2009|
|Personal Health and Demographic Risk Factors|
|Age 85 or older||Gaspar, 1999|
|Female||Bennett, Thomas, & Riegel, 2004; Stookey, Pieper, & Cohen, 2005; Mentes & Culp, 2003|
|Functionally semi-dependent (i.e., those individuals who are cognitively unaware of their needs yet have mobility, and those who are physically unable to meet their needs but who can express them)||Gaspar, 1988|
|Functionally more independent||Mentes & Culp, 2003|
|Semi-dependent with eating||Gaspar, 1999|
|Refuses to drink (i.e., those who are capable of safely consuming liquids but who do not because they worry about incontinence issues [fears of incontinence] or because they say they have never consumed many fluids [sippers])||Mentes, 2006|
|Alzheimer’s disease or other dementias||Albert, Nakra, Grossberg, & Caminal, 1989, 1993|
|Four or more chronic conditions||Lavizzo-Mourey, Johnson, & Stolley, 1988|
|Four or more medications||Lavizzo-Mourey, Johnson, & Stolley, 1988|
|Fever||Pals et al., 1995; Weinberg et al., 1994|
|Few fluid ingestion opportunities||Gaspar, 1988, 1999|
|Inadequate nutrient intake||Gaspar, 1999|
|Inadequate staff and professional supervision||Kayser-Jones, Schell, Porter, Barbaccia, & Shaw, 1999|
|Depression and loneliness associated with decreased fluid intake as identified by nursing home staff||Mentes, Chang, & Morris, 2006|
|Family or caregivers not spending time with the older adult/not being supportive associated with decreased fluid intake as identified by nursing home staff||Mentes, Chang, & Morris, 2006|
Relative Strength of Signs of Dehydration In Older Adults
|Parameter||Physical Sign||Strength of Indicator|
|Vital signs||Rapid pulsea,b||++|
|Oral mucous membranes||Dry, pale, decreased salivaa,b,c||+++|
|Sternal skin turgor||Decreasedb,c||+/−|
|Upper body control||Muscle weaknessa||++++|
Approximate Ranges of Laboratory Tests for Hydration Status
|Blood urea nitrogen/creatinine ratio||20 to 24||>25|
|Hematocrit||Male: 42% to 52%||>52%|
|Female: 35% to 47%||>47%|
|Serum osmolality||280 to 300 mOsm/kg||>300 mOsm/kg|
|Serum sodium||135 to 145 mEq/L||>150 mEq/L|
|Urine osmolality||700 to 1,050 mOsm/kg||>1050 mOsm/kg|
|Urine-specific gravitya||1.020 to 1.029||>1.029|
|Urine colorb||Dark yellow||Greenish-brown|
|Amount of urine||800 to 1,200 cc per day||<800 cc per day|