Journal of Gerontological Nursing

Evidence-Based Practice Guideline 

Hydration Management

Janet C. Mentes, PhD, APRN, BC, FGSA; Sarah Kang, MSN, RN

Abstract

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…

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).

Purpose

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.

Definitions

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

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).

Isotonic Dehydration

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.

Hypertonic Dehydration

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.

Dehydration Risk Factors

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).

Stroke

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.

Surgical Intervention

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).

End-of-Life Considerations

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.

Care Setting

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).

Hydration Intervention

Risk Assessment

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).

Relative Strength of Signs of Dehydration In Older Adults

Table 2: Relative Strength of Signs of Dehydration In Older Adults

Approximate Ranges of Laboratory Tests for Hydration Status

Table 3: Approximate Ranges of Laboratory Tests for Hydration Status

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.

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.

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.

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.

Hydration Management

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:

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.

References

  • Agency for Healthcare Research and Quality. (2007). Prevention quality indicators download. AHRQ quality indicators. Rockville, MD: Author.
  • Agency for Healthcare Research and Quality. (2008). Healthcare cost and utilization project. Rockville, MD: Author.
  • Ainslie, P.N., Campbell, I.T., Frayn, K.N., Hymphreys, S.M., MacLaren, D.P., Reilly, T. & Westerterp, K.R. (2002). Energy balance, metabolism, hydration, and performance during strenuous hill walking: The effect of age. Journal of Applied Physiology, 93, 714–723. doi:
  • Albert, S.G., Nakra, B.R., Grossberg, G.T. & Caminal, E.R. (1989). Vasopressin response to dehydration in Alzheimer’s disease. Journal of the American Geriatrics Society, 37, 843–847.
  • Albert, S.G., Nakra, B.R., Grossberg, G.T. & Caminal, E.R. (1993). Drinking behavior and vasopressin responses to hyperosmolality in Alzheimer’s disease. International Psychogeriatrics, 6, 79–86. doi:10.1017/S104161029400164X [CrossRef]
  • American Society of Anesthesiologist Task Force on Preoperative Fasting. (1999). Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures. Anesthesiology, 90, 896–905.
  • Armstrong, L.E., Maresh, C.M., Castellani, J.W., Bergeron, M.F., Kenefick, R.W., La Grasse, K.E. & Riebe, D. (1994). Urinary indices of hydration status. International Journal of Sport Nutrition, 4, 265–279.
  • Batscha, C. (1997). Heat stroke. Keeping your patients cool in the summer. Journal of Psychosocial Nursing and Mental Health Services, 35(7), 12–17.
  • Beaujean, D.J., Blok, H.E., Vandenbroucke-Grauls, C.M., Weersink, A.J., Raymakers, J.A. & Verhoef, J. (1997). Surveillance of nosocomial infections in geriatric patients. Journal of Hospital Infection, 36, 275–284. doi:10.1016/S0195-6701(97)90054-2 [CrossRef]
  • Bennett, J.A., Thomas, V. & Riegel, B. (2004). Unrecognized chronic dehydration in older adults. Journal of Gerontological Nursing, 30(11), 22–28.
  • Bossingham, M.J., Carnell, N.S. & Campbell, W.W. (2005). Water balance, hydration status, and fat-free mass hydration in younger and older adults. American Journal of Clinical Nutrition, 81, 1342–1350.
  • Bristow, M.F. & Kohen, D. (1996). Neuroleptic malignant syndrome. British Journal of Hospital Medicine, 55, 517–520.
  • Bruera, E., Belzile, M., Watanabe, S. & Fainsinger, R.L. (1996). Volume of hydration in terminal cancer patients. Supportive Care in Cancer, 4, 147–150. doi:10.1007/BF01845764 [CrossRef]
  • Bruera, E., Sala, R., Rico, M.A., Moyano, J., Centeno, C., Wille, J. & Palmer, J.L. (2005). Effects of parenteral hydration in terminally ill cancer patients: A preliminary study. Journal of Clinical Oncology, 23, 2366–2371. doi:10.1200/JCO.2005.04.069 [CrossRef]
  • Bulechek, G., Butcher, H. & McCloskey-Dochterman, J. (Eds.). (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis: Mosby Elsevier.
  • Burge, F.I. (1993). Dehydration symptoms of palliative care cancer patients. Journal of Pain Symptom Management, 8, 454–464. doi:10.1016/0885-3924(93)90188-2 [CrossRef]
  • Chan, J., Knutsen, S.F., Blix, G.G., Lee, J.W. & Fraser, G.E. (2002). Water, other fluids, and fatal coronary heart disease: The Adventist Health Study. American Journal of Epidemiology, 155, 827–833. doi:10.1093/aje/155.9.827 [CrossRef]
  • Chassagne, P., Druesne, L., Capet, C., Ménard, J.F. & Bercoff, E. (2006). Clinical presentation of hypernatremia in elderly patients: A case control study. Journal of the American Geriatrics Society, 54, 1225–1230. doi:10.1111/j.1532-5415.2006.00807.x [CrossRef]
  • Cosgray, R., Davidhizar, R., Giger, J.N. & Kreisl, R. (1993). A program for water-intoxicated patients at a state hospital. Clinical Nurse Specialist, 7(2), 55–61. doi:10.1097/00002800-199303000-00004 [CrossRef]
  • Crenshaw, J.T. & Winslow, E.H. (2002). Preoperative fasting: Old habits die hard. American Journal of Nursing, 102(5), 36–44. doi:10.1097/00000446-200205000-00033 [CrossRef]
  • Doucet, J., Jego, A., Noel, D., Geffroy, C., Capet, C., Coquard, A. & Bercoff, E. (2002). Preventable and non-preventable risk factors for adverse drug events related to hospital admissions in the elderly. Clinical Drug Investigation, 22, 385–392. doi:10.2165/00044011-200222060-00006 [CrossRef]
  • Eaton, D., Bannister, P., Mulley, G.P. & Connolly, M.J. (1994). Axillary sweat in clinical assessment of dehydration in ill elderly patients. BMJ, 308, 1271. doi:10.1136/bmj.308.6939.1271 [CrossRef]
  • Ellershaw, J.E., Sutcliffe, J.M. & Saunders, C.M. (1995). Dehydration and the dying patient. Journal of Pain Symptom Management, 10, 192–197. doi:10.1016/0885-3924(94)00123-3 [CrossRef]
  • Fainsinger, R.L. & Bruera, E. (1997). When to treat dehydration in a terminally ill patient?Support Care Cancer, 5, 205–211. doi:10.1007/s005200050061 [CrossRef]
  • Farrell, M.J., Zamarripa, F., Shade, R., Phillips, P.A., McKinley, M., Fox, P.T. & Egan, G.F. (2008). Effects of aging on regional cerebral blood flow responses associated with osmotic thirst and its satiation by water drinking: A PET study. Proceedings of the National Academy of Science, 105, 382–387. doi:10.1073/pnas.0710572105 [CrossRef]
  • Faull, C.M., Holmes, C. & Baylis, P.H. (1993). Water balance in elderly people: Is there a deficiency of vasopressin?Age and Aging, 22, 114–120. doi:10.1093/ageing/22.2.114 [CrossRef]
  • Foreman, M.D. (1989). Confusion in hospitalized elderly: Incidence, onset and associated factors. Research in Nursing & Health, 12, 21–29. doi:10.1002/nur.4770120105 [CrossRef]
  • Gaspar, P.M. (1988). What determines how much patients drink?Geriatric Nursing, 9, 221–224. doi:10.1016/S0197-4572(88)80145-9 [CrossRef]
  • Gaspar, P.M. (1999). Water intake of nursing home residents. Journal of Gerontological Nursing, 25(4), 22–29.
  • Gaspar, P.M. (2011). Comparisons of four standards for determining adequate water intake of nursing home residents. Research & Theory for Nursing Practice, 25, 11–22. doi:10.1891/0889-7182.25.1.11 [CrossRef]
  • Gordon, J.A., An, L.C., Hayward, R.A. & Williams, B.C. (1998). Initial emergency department diagnosis and return visits: Risk versus perception. Annals of Emergency Medicine, 32, 569–573. doi:10.1016/S0196-0644(98)70034-4 [CrossRef]
  • Gross, C.R., Lindquist, R.D., Woolley, A.C., Granieri, R., Allard, K. & Webster, B. (1992). Clinical indicators of dehydration severity in elderly patients. The Journal of Emergency Medicine, 10, 267–274. doi:10.1016/0736-4679(92)90331-M [CrossRef]
  • Hodgkinson, B., Evans, D. & Wood, J. (2003). Maintaining oral hydration in older adults: A systematic review. International Journal of Nursing Practice, 9, S19–S28. doi:10.1046/j.1440-172X.2003.00425.x [CrossRef]
  • Hooper, L., Attreed, N.J., Campbell, W.W., Channell, A.M., Chassagne, P., Culp, K.R. & Hunter, P.R. (2012). Clinical and physical signs for identification of impending and current water loss dehydration in older people. Cochrane Database of Systematic Reviews, 2. doi:10.1002/14651858.CD009647 [CrossRef]
  • Institute of Medicine. (2005). Dietary reference intakes for water, potassium, sodium, chloride, and sulfate. Retrieved from the National Academies Press website: http://www.nap.edu/catalog/10925.html
  • Jacobs, L.G. (1996). The neuroleptic malignant syndrome: Often an unrecognized geriatric problem. Journal of the American Geriatrics Society, 44, 474–475.
  • Josseran, L., Caillere, N., Brun-Ney, D., Rottner, J., Filleul, L., Brucker, G. & Astagneau, P. (2009). Syndromic surveillance and heat wave morbidity: A pilot study based on emergency departments in France. BMC Medical Informatics and Decision Making, 9, 14. doi:10.1186/1472-6947-9-14 [CrossRef] .
  • Kavouras, S. (2002). Assessing hydration status. Current Opinion in Clinical Nutrition and Metabolic Care, 5, 519–524. doi:10.1097/00075197-200209000-00010 [CrossRef]
  • Kayser-Jones, J., Schell, E.S., Porter, C., Barbaccia, J.C. & Shaw, H. (1999). Factors contributing to dehydration in nursing homes: Inadequate staffing and lack of professional supervision. Journal of the American Geriatrics Society, 47, 1187–1194.
  • Kelly, J., Hunt, B.J., Lewis, R.R., Swaminathan, R., Moody, A., Seed, P.T. & Rudd, A. (2004). Dehydration and venous thromboembolism after acute stroke. QJM, 97, 293–296. doi:10.1093/qjmed/hch050 [CrossRef]
  • Kenny, W.L. & Chiu, P. (2001). Influence of age on thirst and fluid intake. Medicine & Science in Sports and Exercise, 33, 1524–1532. doi:10.1097/00005768-200109000-00016 [CrossRef]
  • Lavizzo-Mourey, R., Johnson, J. & Stolley, P. (1988). Risk factors for dehydration among elderly nursing home residents. Journal of the American Geriatrics Society, 36, 213–218.
  • Leaf, A. (1984). Dehydration in elderly. New England Journal of Medicine, 311, 791–792. doi:10.1056/NEJM198409203111209 [CrossRef]
  • Lindeman, R.D., Tobin, J. & Shock, N.W. (1985). Longitudinal studies on the rate of decline in renal function with age. Journal of the American Geriatrics Society, 33, 278–285.
  • Mange, K., Matsuura, D., Cizman, B., Soto, H., Ziyadeh, F.N., Goldfarb, S. & Neilson, E.G. (1997). Language guiding therapy: The case of dehydration versus volume depletion. Annals of Internal Medicine, 127, 848–853.
  • Martof, M.T. & Knox, D.K. (1997). The effect of xanthines on fluid balance. Clinical Nursing Research, 6, 186–196. doi:10.1177/105477389700600207 [CrossRef]
  • Masotti, L., Ceccarelli, E., Cappelli, R., Barabesi, L., Guerrini, M. & Forconi, S. (2000). Length of hospitalization in elderly patients with community acquired pneumonia. Aging Clinical Experimental Research, 12, 35–41.
  • Maughan, R.J. & Griffin, J. (2003). Caffeine ingestion and fluid balance: A review. Journal of Human Nutrition and Dietetics, 16, 411–420. doi:10.1046/j.1365-277X.2003.00477.x [CrossRef]
  • Meier, D.E., Ahronheim, J.C., Morris, J., Baskin-Lyons, S. & Morrison, R.S. (2001). High short-term mortality in hospitalized patients with advanced dementia: Lack of benefit of tube feeding. Archives of Internal Medicine, 161, 594–599. doi:10.1001/archinte.161.4.594 [CrossRef]
  • Mentes, J.C. (2006). A typology of oral hydration problems exhibited by frail nursing home residents. Journal of Gerontological Nursing, 32(1), 13–19.
  • Mentes, J.C., Chang, B.L. & Morris, J. (2006). Keeping nursing home residents hydrated. Western Journal of Nursing Research, 28, 392–406. doi:10.1177/0193945906286607 [CrossRef]
  • Mentes, J.C. & Culp, K. (2003). Reducing hydration-linked events in nursing home residents. Clinical Nursing Research, 12, 210–225. doi:10.1177/1054773803252996 [CrossRef]
  • Mentes, J.C., Culp, K., Maas, M. & Rantz, M. (1999). Acute confusion indicators: Risk factors and prevalence using MDS data. Research in Nursing & Health, 22, 95–105. doi:10.1002/(SICI)1098-240X(199904)22:2<95::AID-NUR2>3.0.CO;2-R [CrossRef]
  • Mentes, J. & Kang, S. (2011). Hydration management evidence-based protocol. Iowa City: John A. Hartford Foundation Center of Nursing Excellence, University of Iowa College of Nursing.
  • Mentes, J.C., Wakefield, B. & Culp, K. (2006). Use of a urine color chart to monitor hydration status in nursing home residents. Biological Research for Nursing, 7, 197–203. doi:10.1177/1099800405281607 [CrossRef]
  • Mentes, J.C. & Wang, J. (2011). Measuring risk for dehydration in nursing home residents: Evaluation of the Dehydration Risk Appraisal Checklist. Research in Gerontological Nursing, 4, 148–156. doi:10.3928/19404921-20100504-02 [CrossRef]
  • Michaud, D.S., Spiegelman, D., Clinton, S.K., Rimm, E.B., Curhan, G.G., Willett, W.C. & Giovannucci, E.L. (1999). Fluid intake and the risk of bladder cancer in men. New England Journal of Medicine, 340, 1390–1397. doi:10.1056/NEJM199905063401803 [CrossRef]
  • Mion, L.C. & O’Connell, A. (2003). Parenteral hydration and nutrition in the geriatric patient: Clinical and ethical issues. Journal of Infusion Nursing, 26, 144–152. doi:10.1097/00129804-200305000-00005 [CrossRef]
  • Mitchell, S.L, Kiely, D.K. & Lipsitz, L.A. (1997). The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Archives of Internal Medicine, 157, 327–332. doi:10.1001/archinte.1997.00440240091014 [CrossRef]
  • Morgan, A.L., Masterson, M.M., Fahlman, M.M., Topp, R.V. & Boardley, D. (2003). Hydration status of community-dwelling seniors. Aging Clinical and Experimental Research, 15, 301–304.
  • Morita, T., Tei, Y., Tsunoda, J., Inoue, S. & Chihara, S. (2001). Determinants of the sensation of thirst in terminally ill cancer patients. Supportive Care in Cancer, 9, 177–186. doi:10.1007/s005200000205 [CrossRef]
  • Mukand, J.A., Cai, C., Zielinski, A., Danish, M. & Berman, J. (2003). The effects of dehydration on rehabilitation outcomes of elderly orthopedic patients. Archives of Physical Medicine Rehabilitation, 84, 58–61. doi:10.1053/apmr.2003.50064 [CrossRef]
  • O’Keeffe, S.T. & Lavan, J.N. (1996). Predicting delirium in elderly patients: Development and validation of a risk-stratification model. Age and Aging, 25, 317–321. doi:10.1093/ageing/25.4.317 [CrossRef]
  • O’Neill, P.A., Duggan, J. & Davies, I. (1997). Response to dehydration in elderly patients in long-term care. Aging Clinical Experimental Research, 9, 372–377.
  • Pals, J.K., Weinberg, A.D., Beal, L.F., Levesque, P.G., Cunningham, T.J. & Minaker, K.L. (1995). Clinical triggers for detection of fever and dehydration: Implications for long-term care nursing. Journal of Gerontological Nursing, 21(4), 13–19.
  • Phillips, P.A., Bretherton, M., Johnston, C.I. & Gray, L. (1991). Reduced osmotic thirst in healthy elderly men. American Journal of Physiology, 261, R166–R171.
  • Popkin, B.M. (2010). Patterns of beverage use across the lifecycle. Physiology & Behavior, 100, 4–9. doi:10.1016/j.physbeh.2009.12.022 [CrossRef]
  • Rasouli, M., Kiasari, A.M. & Arab, S. (2008). Indicators of dehydration and hemoconcentration are associated with the prevalence and severity of coronary artery disease. Clinical and Experimental Pharmacology and Physiology, 35, 889–894. doi:10.1111/j.1440-1681.2008.04932.x [CrossRef]
  • Robinson, S.B. & Rosher, R.B. (2002). Can a beverage cart help improve hydration?Geriatric Nursing, 23, 208–211. doi:10.1067/mgn.2002.126967 [CrossRef]
  • Rodriguez, G.J., Cordina, S.M., Vazquez, G., Suri, M.F., Kirmani, J.F., Ezzeddine, M.A. & Queshi, A.I. (2009). The Hydration Influence on the Risk of Stroke (THIRST) study. Neurocritical Care, 10, 187–194. doi:10.1007/s12028-008-9169-5 [CrossRef]
  • Rowe, J.W., Shock, N.W. & DeFronzo, R.A. (1976). The influence of age on the renal response to water deprivation in man. Nephron, 17, 270–278. doi:10.1159/000180731 [CrossRef]
  • Sachdev, P., Mason, C. & Hadzi-Pavlovic, D. (1997). Case-control study of neuroleptic malignant syndrome. American Journal of Psychiatry, 154, 1156–1158.
  • Schmidlin, E. (2008). Artificial hydration: The role of the nurse in addressing patient and family needs. International Journal of Palliative Nursing, 14, 485–489.
  • Silver, A.J. (1990). Aging and risks for dehydration. Cleveland Clinic Journal of Medicine, 57, 341–344.
  • Simmons, S.F., Alessi, C. & Schnelle, J.F. (2001). An intervention to increase fluid intake in nursing home residents: Prompting and preference compliance. Journal of the American Geriatrics Society, 49, 926–933. doi:10.1046/j.1532-5415.2001.49183.x [CrossRef]
  • Skipper, A. (1993). Dietitian’s handbook of enteral and parenteral nutrition. Rockville, MD: Aspen.
  • Smith, A.F., Vallance, H. & Slater, R.M. (1997). Shorter preoperative fluid fasts reduce postoperative emesis. BMJ, 314, 1486. doi:10.1136/bmj.314.7092.1486a [CrossRef]
  • Stookey, J.D., Pieper, C.F. & Cohen, H.J. (2005). Is the prevalence of dehydration among community-dwelling older adults really low? Informing current debate over the fluid recommendation for adults aged 70+ years. Public Health Nutrition, 8, 1275–1285. doi:10.1079/PHN2005829 [CrossRef]
  • Vivanti, A., Harvey, K., Ash, S. & Battistutta, D. (2008). Clinical assessment of dehydration in older people admitted to hospital. What are the strongest indicators?Archives of Gerontology and Geriatrics, 47, 340–355. doi:10.1016/j.archger.2007.08.016 [CrossRef]
  • Wakefield, B.J., Mentes, J., Holman, J.E. & Culp, K. (2009). Postadmission dehydration: Risk factors, indicators, and outcomes. Rehabilitation Nursing, 34, 209–216. doi:10.1002/j.2048-7940.2009.tb00281.x [CrossRef]
  • Warren, J.L., Bacon, W.E., Harris, T., McBean, A.M., Foley, D.J. & Phillips, C. (1994). The burden and outcomes associated with dehydration among US elderly, 1991. American Journal of Public Health, 84, 1265–1269. doi:10.2105/AJPH.84.8.1265 [CrossRef]
  • Weinberg, A. & Minaker, K. (1995). Dehydration. Evaluation and management in older adults. Journal of the American Medical Association, 274, 1562–1556. doi:10.1001/jama.1995.03530190066035 [CrossRef]
  • Weinberg, A.D., Pals, J.K., Levesque, P.G., Beals, L.F., Cunningham, T.J. & Minaker, K.L. (1994). Dehydration and death during febrile episodes in the nursing home. Journal of the American Geriatrics Society, 42, 968–971.
  • Whelan, K. (2001). Inadequate fluid intakes in dysphagic acute stroke. Clinical Nutrition, 20, 423–428. doi:10.1054/clnu.2001.0467 [CrossRef]
  • Xiao, H., Barber, J. & Campbell, E.S. (2004). Economic burden of dehydration among hospitalized elderly patients. American Journal of Health-System Pharmacists, 61, 2534–2540.
  • Yogendran, S., Asokumar, B., Cheng, D. & Chung, F. (1995). A prospective randomized double-blinded study of the effect of intravenous fluid therapy on adverse outcomes on outpatient surgery. Anesthesia & Analgesia, 80, 682–686.
  • Zembrzuski, C. (1997). A three-dimensional approach to hydration of elders: Administration, clinical staff, and in-service education. Geriatric Nursing, 18, 20–26. doi:10.1016/S0197-4572(97)90126-9 [CrossRef]
  • Zizza, C.A., Ellison, K.J. & Wernette, C.M. (2009). Total water intakes of community-living middle-old and oldest-old adults. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 64, 481–486. doi:10.1093/gerona/gln045 [CrossRef]

Dehydration Risk Factors

Age-Related Physiological ChangesSources
Altered thirst perception in older menFarrell 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 waterLindeman, Tobin, & Shock, 1985; Rowe, Shock, & DeFronzo, 1976
Decreased effectiveness of vasopressinFaull, Holmes, & Baylis, 1993; O’Neill, Duggan, & Davies, 1997; Phillips et al., 1993
Increased prevalence of multiple chronic diseasesMorgan, Masterson, Fahlman, Topp, & Boardley, 2003
Poor tolerance for hot weatherJosseran et al., 2009
Personal Health and Demographic Risk Factors
Age 85 or olderGaspar, 1999
FemaleBennett, 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 independentMentes & Culp, 2003
Semi-dependent with eatingGaspar, 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 dementiasAlbert, Nakra, Grossberg, & Caminal, 1989, 1993
Four or more chronic conditionsLavizzo-Mourey, Johnson, & Stolley, 1988
Four or more medicationsLavizzo-Mourey, Johnson, & Stolley, 1988
FeverPals et al., 1995; Weinberg et al., 1994
Few fluid ingestion opportunitiesGaspar, 1988, 1999
Inadequate nutrient intakeGaspar, 1999
Inadequate staff and professional supervisionKayser-Jones, Schell, Porter, Barbaccia, & Shaw, 1999
Depression and loneliness associated with decreased fluid intake as identified by nursing home staffMentes, 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 staffMentes, Chang, & Morris, 2006

Relative Strength of Signs of Dehydration In Older Adults

ParameterPhysical SignStrength of Indicator
Vital signsRapid pulsea,b++
Orthostatic hypotensionb,c+/−
WeightAcute decrease+++
Oral mucous membranesDry, pale, decreased salivaa,b,c+++
TongueLongitudinal furrowsa+++
Drya+++
Sternal skin turgorDecreasedb,c+/−
EyesSunkena++
Axillary sweatDecreasedd+
SpeechDifficultiesa+++
ConfusionAcute onseta++
Upper body controlMuscle weaknessa++++

Approximate Ranges of Laboratory Tests for Hydration Status

TestImpending DehydrationDehydration
Blood urea nitrogen/creatinine ratio20 to 24>25
HematocritMale: 42% to 52%>52%
Female: 35% to 47%>47%
Serum osmolality280 to 300 mOsm/kg>300 mOsm/kg
Serum sodium135 to 145 mEq/L>150 mEq/L
Urine osmolality700 to 1,050 mOsm/kg>1050 mOsm/kg
Urine-specific gravitya1.020 to 1.029>1.029
Urine colorbDark yellowGreenish-brown
Amount of urine800 to 1,200 cc per day<800 cc per day
Authors

Dr. Mentes is Associate Professor, University of California, Los Angeles (UCLA) School of Nursing, and Ms. Kang is Clinical Nurse 1, Cedars Sinai Medical Center, Los Angeles, California. Dr. Schoenfelder is Associate Clinical Professor and Editor, John A. Hartford Center for Geriatric Excellence, The University of Iowa, Iowa City, Iowa.

The authors have disclosed no potential conflicts of interest, financial or otherwise. Guidelines in this series were originally produced with support provided by grant P30 NR03979 (PI: Toni Tripp-Reimer, The University of Iowa College of Nursing), National Institute of Nursing Research, National Institutes of Health. Copyright © 2011 The University of Iowa John A. Hartford Foundation Center of Geriatric Nursing Excellence.

Address correspondence to Janet C. Mentes, PhD, APRN, BC, FGSA, Associate Professor, UCLA School of Nursing, 5-262 Factor Building, Los Angeles, CA 90095-1702; e-mail: jmentes@sonnet.ucla.edu.

doi:10.3928/00989134-20130110-01

10.3928/00989134-20130110-01

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