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Journals
Journal of Gerontological Nursing

Evidence-Based Practice Guideline Supplemental Data

Hydration Management

Janet C. Mentes, PhD, RN, FGSA, FAAN; Phyllis M. Gaspar, PhD, RN

Abstract

Optimal hydration is essential to health, yet many common health problems of older adults are exacerbated by suboptimal hydration, including falls, adverse medication events, and urinary tract infections to name a few. Understanding dehydration in older adults is difficult, and causes for inadequate intake are multifocal. The current article provides important care guidelines on assessing risk and providing essential interventions to prevent dehydration. [Journal of Gerontological Nursing, 46(2), 19–30.]

Abstract

Optimal hydration is essential to health, yet many common health problems of older adults are exacerbated by suboptimal hydration, including falls, adverse medication events, and urinary tract infections to name a few. Understanding dehydration in older adults is difficult, and causes for inadequate intake are multifocal. The current article provides important care guidelines on assessing risk and providing essential interventions to prevent dehydration. [Journal of Gerontological Nursing, 46(2), 19–30.]

Dehydration is a serious problem for older adults, which occurs as a precipitating and comorbid condition leading to unnecessary hospitalizations. Adults older than 65 continue to have the highest rates of admissions for dehydration as a primary diagnosis, with those older than 75 having the highest rates at 750 per 100,000 (Agency for Healthcare Research & Quality [AHRQ], 2015). The annual cost estimate for a primary diagnosis of dehydration is >$1.14 billion (Xiao, Barber, & Campbell, 2004), with secondary dehydration raising the cost of a hospitalization (Mentes & Aronow, 2016), suggesting that the cost of dehydration is underestimated.

Current data for inpatient hospitalizations for adults 65 and older indicate that septicemia is increasingly prevalent at 7.6% of admissions (AHRQ, 2017), which is often linked to hydration status and the outcome of a period of chronic under-hydration. Warren et al. (1994) found that 18% of Medicare patients hospitalized with a diagnosis of dehydration died within 30 days and approximately one half died within 1 year of diagnosis. (There have been no recent studies updating this statistic.) Given that dehydration is often a hidden comorbidity in many health conditions of older adults, it is likely that this observation is still valid (Mentes & Aronow, 2016).

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. The current article is a summary of the evidence-based practice guideline Hydration Management (Mentes & Gaspar, 2020), which is available for purchase from The University of Iowa Barbara and Richard Csomay Center for Gerontological Excellence (access www.UIowaCsomayGeroResources. com). The purpose of this evidence-based protocol is to help health care providers in all settings determine adequate oral fluid intake for older adults and to use strategies that will improve and maintain hydration. The need for implementation of the protocol is supported by a prevalence of dehydration among residents of long-term care that has been consistently reported as ranging from 20% to 40% (Hooper, Bunn, Abdelhamid, et al., 2016; Johnson & Hahn, 2018; Lesnik, Piko, Zeleznik, & Bevc, 2017), with the exception of Paulis, Everink, Halfens, Lohrmann, and Schols (2018) who reported a wide prevalence from 0.8% to 38.5%. On a similar note, residents of long-term care facilities have been reported to have inadequate water intake, which is a common factor leading to dehydration (Botiqué et al., 2019; Gaspar, 1988, 1999, 2011; Gaspar, Scherb, & Rivera-Mariani, 2019; Marra et al., 2016; Namasivayam et al., 2018). Use of this protocol will help prevent dehydration and associated conditions, such as acute confusion/delirium (Foreman, 1989; Mentes, Culp, Maas, & Rantz, 1999; O'Keeffe & Lavan, 1996; Seymour, Henschke, Cape, & Campbell, 1980), adverse drug reactions (Doucet et al., 2002), infections (Beaujean et al., 1997; Masotti et al., 2000; Murray, Doeltgen, Miller, & Scholten, 2016), increased mortality in general (El-Sharkawy et al., 2015) and specifically 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).

It is important to address hospitalization and re-hospitalization of older adults as related to dehydration. The 2015 AHRQ report indicates that older adults have the highest rate of hospital admission with dehydration as the primary diagnosis. El-Sharkawy et al. (2014) found that 40% of older adults were dehydrated on hospital admission and that the number increased to 44% at 48 hours. Approximately one fourth of hospitalized older adults had water loss dehydration and 19% had water solute dehydration (Fortes et al., 2015). Dehydration has been associated with longer hospital stays for rehabilitation (Frangeskou et al., 2015; Mukand, Cai, Zielinksi, Danish, & Berman, 2003), readmission to the hospital (Frangeskou et al., 2014; Gordon, An, Hayward, & Williams, 1998), and excess cost of hospitalization (Frangeskou, Lopez-Valcarel, & Serra-Maiem, 2015; Xiao et al., 2004). Hospitalization costs are even higher when dehydration is a comorbid condition during an older adult's hospitalization (Frangeskou et al., 2015; Mentes & Aronow, 2016). Even in healthy community-dwelling older adults, physical performance and cognitive processing are affected by mild dehydration (Ainslie et al., 2002). The focus of this guideline 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. This guideline does not include interventions for acute/emergent rehydration of older adults.

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, Dochterman, & Wagner, 2012, p. 200).

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 discuss hydration management for older adults (Weinberg & Minaker, 1995).

Hypotonic Dehydration

Hypotonic dehydration, also known as extracellular fluid volume depletion, is depletion in 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 affected in hypotonic dehydration (Leaf, 1984; Silver, 1990).

Isotonic Dehydration

Isotonic 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

Hypertonic 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). This dehydration 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 FactorsDehydration 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 over- and underhydration. 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). Polyuria due to lithium treatment in community-dwelling adults with bipolar disorder may also put them at risk for dehydration and death (Kinahan et al., 2015). In addition, in individuals with persistent mental illness, risks for overhydration stem from a combination of the drying side effects of prescribed psychotropic medications and the individual's compulsive behaviors that 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 an approximate three- to five-fold increase in the risk of hospitalized stroke patients acquiring a venous thromboembolism. Another sequela of stroke is dysphagia, which can cause dehydration (Murray, Doeltgen, Miller, & Scholten, 2015; Whelan, 2001). This potential for dehydration appears to be related not only to the dysphagia resulting from the stroke but also the poor palatability of the thickened fluids offered to patients to prevent aspiration (Lin, Lee, Hung, Chang, & Yang; 2014; McGrail & Kelchner, 2015). 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 Anesthesiologists (ASA) Task Force on Preoperative Fasting, patients were still being instructed to fast too long prior to surgery. In fact, patients may safely consume clear liquids up to 2 hours before elective surgery using general anesthesia, regional anesthesia, or sedation-anesthesia (ASA Committee, 2011).

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).

On the other hand, Bruera et al. (1996) determined that small amounts of fluids delivered subcutaneously via hypodermoclysis plus opioid rotation was effective in decreasing delirium and antipsychotic use and did not cause edema in terminally ill patients. Bruera et al. (2005) also found in a 2-day pilot study that parenteral hydration in terminally ill cancer patients led to statistically significant decreases in hallucination, myoclonus, fatigue, and sedation, but in a larger clinical trial, no benefit to parenteral hydration was found for cancer patients in a hospice setting (Bruera et al., 2013). Research also suggests artificial hydration does not prolong life (Bruera et al., 2005; Bruera et al., 2013; Meier, Ahronheim, Morris, Baskin-Lyons, & Morrison, 2001).

Therefore, it is recommended that maintaining or withholding fluids at the end of life be an individual decision based on the etiology of illness, use of medications, presence of delirium, and patient and family preferences (Bruera et al., 2013; Fainsinger & Bruera, 1997; Morita et al., 2001; Schmidlin, 2008). Schmidlin (2008) and Bruera et al. (2013) recommend 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, poly-pharmacy, 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

Appropriate Ranges of Laboratory Tests for Hydration Status

Table 3:

Appropriate Ranges of Laboratory Tests for Hydration Status

Dehydration risk appraisal checklist.Note. MMSE = Mini-Mental State Examination; ADLs = activities of daily living; GDS = Geriatric Depression Scale; BMI = body mass index. Reprinted with permission from Mentes & Wang (2011).

Figure 1.

Dehydration risk appraisal checklist.

Note. MMSE = Mini-Mental State Examination; ADLs = activities of daily living; GDS = Geriatric Depression Scale; BMI = body mass index. Reprinted with permission from Mentes & Wang (2011).

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 (two of 14 individuals) and included independent adults and those who forget to drink. The “Can't Drink” group had a 38% risk (five of 13 individuals) and included people with swallowing limitations and those who were physically dependent. The “Won't Drink” group had a 57% risk (four of seven 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 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 residents' drinking habits. The tailored guide can be helpful in maximizing hydration for individual older adults.

Types of hydration problems and suggested strategies. Reprinted with permission from Mentes (2006).

Figure 2.

Types of hydration problems and suggested strategies. Reprinted with permission from Mentes (2006).

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 age 70 and older. However, this estimate is for older adults who are active and 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. The nomogram is available in the full guideline (access www.UIowaCsomayGeroResources.com).

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 consumption, 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 (Godfrey, Cloete, Dymond, & Long, 2012; Mentes, Chang, et al., 2006; Oates & Price 2017; Robinson & Rosher, 2002; Schnelle et al., 2010; 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 (Table A, available in the online version of this article).

Interventions and StrategiesInterventions and Strategies

Table A:

Interventions and Strategies

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 serially at several indicators, such as oral hydration habits and urine parameters, including urine color and specific gravity (Mentes, 2006). A single measurement will not be as helpful as looking at the individual's pattern in these measures. 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 age 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 carefully assess 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 & Gaspar, 2020). 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 older adults are not feeling well, as several missed meals can contribute to hydration problems. Through use of the Hydration Management evidence-based practice guideline (Mentes & Gaspar, 2020), dehydration episodes in older adults can be decreased and unnecessary emergency department visits and hospitalizations may be avoided.

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  • Weinberg, A. D., Pals, J. K., Levesque, P. G., Beal, 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(9), 968–971 doi:10.1111/j.1532-5415.1994.tb06589.x [CrossRef] PMID:8064106
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Dehydration Risk Factors

Risk FactorSource
Age-Related Physiological Changes
Altered thirst perception in older menFarrell et al., 2008; Mack et al., 1994; Miescher & Fortney, 1989; Phillips, Bretherton, Johnston, & Gray, 1991; Phillips et al., 1984; Vivanti, Harvey, & Ash, 2010
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; Lavizzo-Mourey, Johnson, & Stolley, 1988
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, Johnston, & Gray 1993
Increased prevalence of multiple chronic diseasesHooper, Bunn, Jimoh, & Fairweather-Tait, 2014; Morgan, Masterson, Fahlman, Topp, & Boardley, 2003
Poor tolerance for hot weatherJosseran et al., 2009
Personal Health and Demographic Risk Factors
Age ≥85/≥70 yearsGaspar, 1999; Lavizzo-Mourey et al., 1988; Marra et al 2016; Murray et al., 2015
FemaleBennett, Thomas, & Riegel, 2004; Gaspar, 1988; Lavizzo-Mourey et al., 1988; Mentes, 2000; Murray et al., 2015; Stookey, Piper, & Cohen, 2005
Dependence in activities of daily livingMarra et al., 2016; Murray et al., 2015
Functionally semi-dependent (i.e., 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 independentGaspar, 1999; Mentes & Culp, 2003
Semi-dependent with eating (needing prompting or some assistance but not completely dependent)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])Gaspar, 1988; Mentes, 2006
Impaired cognitive ability/Alzheimer's disease or other dementiasAlbert, Nakra, Groseberg, & Caminal, 1989, 1994; Hooper, Bunn, Downing, et al., 2016; Marra et al., 2016; Oates & Price, 2017
Four or more chronic conditionsLavizzo-Mourey et al., 1988
Four or more medicationsLavizzo-Mourey et al., 1988
FeverPals et al., 1995; Weinberg et al., 1994
Few fluid ingestion opportunities/missing drinks between mealsGaspar, 1988, 1999; Hooper, Bunn, Downing, et al., 2016
Inadequate nutrient intakeGaspar, 1999; Hooper, Bunn, Downing, et al., 2016; Marra et al., 2016
Inadequate staff and professional supervisionHimmelstein, Jones, & Woolhandler, 1983; Kayser-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 Indicators
Vital signsRapid pulsea,b++
Orthostatic hypotensionb,c+/–
Low systolic blood pressured+++
Axillary temperaturee++
WeightAcute increase+++
Acute decrease+++
Oral mucous membranesDry, pale, decreased salivaa,b,c+++
TongueLongitudinal furrowsa+++
Drya,c+++
Sternal skin turgorDecreasedb,c+/–
EyesSunkena++
Axillary sweatDecreasedf,g+
SpeechDifficultiesa+++
ConfusionAcute onseta++
Upper body controlMuscle weaknessa++++

Appropriate Ranges of Laboratory Tests for Hydration Status

TestNormalImpending DehydrationDehydration
Blood urea nitrogen/creatinine ratio20 to 24>25
HematocritMale: 42% to 52%>52%
Female: 35% to 47%>47%
Serum osmolality<295 mmol/kg295 to 300 mmol/kg>300 mmol/kg
Serum sodium135 to 145 mEq/L>150 mEq/L
Urine osmolality500 to 700 mOsm/kg700 to 1,050 mOsm/kg>1,050 mOsm/kg
Urine-specific gravitya1.005 to 1.0191.020 to 1.029>1.029
Urine colorbPale medium yellowDark yellowGreenish-brown
Amount of urine800 to 1,200 cc/day<800 cc/day

Interventions and Strategies

Interventions and StrategiesReferencesOverall Evidence Grade
Provide fluids consistently throughout the dayBak, Wilson, Tsiami, & Loveday, 2018; Bunn et al., 2015; Ferry, 2005; Hodgkinson, Evans, & Wood, 2003; Jimoh et al., 2015; Jimo et al., 2019; Oats & Price, 2017; Mentes, Chang, & Morris, 2006; Robinson & Rosher, 2002; Simmons, Alessi, & Schnelle, 2001; Volkert et al., 2018A1
   Specific Effective Strategies
Plan fluid intake as follows: 75–80% delivered at meals, and 20–25% delivered during non-mealtimes such as medication times and planned nourishment times.Zembrzuski, 1997; Volkert et al., 2018D
Offer a variety of fluids keeping in mind the individual's previous intake patternBunn et al., 2015; Godfrey et al., 2012; Schnelle et al., 2010; Simmons, Alessi, & Schnelle, 2001; Volkert et al., 2018; Wilson et al., 2018: Zembrzuski, 1997C1
Integrate fluid rounds mid-morning and late afternoon, where caregiver provides additional fluidsSpangler, Risley, & Bilyew, 1984B2
Standardize fluid with medication administrations to a prescribed amount; e.g. 180mL (6oz.) per administration time.Jimoh et al., 2019; Mentes & Culp, 2003B2
Provide 2- 8 oz. glasses of fluid in AM and PMRobinson & Rosher, 2002B2
If taking thickened liquids encourage intake (as intake reported as lower than if taking thin liquids)McGrail & Kelchner, 2012; McGrail & Kelchner, 2015; Painter et al., 2017C1
Select between-meal snacks that will increase water intakeMarra et al., 2016C1
Make Drinking Opportunity a Pleasurable and Social ExperienceAbdelhamid et al., 2016; Godfrey, Cloete, Dymond, & Long, 2012C1
   Specific Effective Strategies
“Happy Hours” in the afternoon, where residents can gather together for additional fluids and socializationMentes, Chang, & Morris, 2006; Munsson et al., 1990C1
“Tea Time” in the afternoon, where residents come together for fluids, nourishment and socializationMueller & Boisen, 1989D
Encourage resident to have meals in the dining roomReed, Zimmerman, Sloane, Williams, & Boustani, 2005; Volkert et al., 2018C1
Create a non-institutional dining experienceReed et al., 2005; Volkert et al., 2018C1
Ensure utensils are resident centered
   Specific Effective Strategies
Use of modified fluid containers based on resident's intake behaviors (e.g. ability to hold cup, to swallow)Bak et al., 2018; Mueller & Boisen, 1989; Reedy, 1988D
Use high contrast tableware during meals for residents with dementiaDunne, Neargarder, Cipolloni, & Cronin-Golomb, 2004D
Encourage on-going intake of fluids throughout the dayBunn et al., 2015; Mentes, Chang, & Morris, 2006; Robinson & Rosher, 2002; Simmons, Alessi, & Schnelle, 2001C1
Provide reminders/prompts to drink fluidsBak et al., 2018; Bunn et al., 2015; Godfrey et al., 2012; Oats & Price 2016C1
Provide the appropriate level of assistance to enhance intakeBunn et al., 2015; Godfrey et al., 2012; Marra et al., 2016C1
Offer a variety of fluids with consideration for residents' preferenceGodfrey et al., 2012; Mentes, Chang, & Morris, 2006; Oates & Price, 2017; Robinson & Rosher, 2002; Schnelle et al., 2010; Simmons, Alessi, & Schnelle, 2001; Wilson et al., 2018C1
Increase toileting routine (in combination with other strategies)Bunn et al. 2015; Schnelle et al., 2010; Spangler et al., 1984; Tanka et al., 2009; Zembrzuski, 2006C1
Provide staff with education on hydration management (in combination with other strategies)Beattie, O'Reilly, Strange, Franklin, & Isenring,2014; Greene et al., 2018; Oats & Price, 2017; Volkert et al., 2018; Zembrzuski, 2006C1
Coordinate staff communication about hydration such as certified nursing assistant (CNA) handoff reports or documentation in nursing care plan.Mentes, Chang, & Morris, 2006; Ullrich, & McCutcheon, 2008C1
Provide a staffing ratio that allows the needs of the residents to be metNamasivayam-MacDonald et al, 2018; Reed et al., 2005C1
   Encourage family involvement and supportMentes, Chang, & Morris, 2006C1
   Promote Self-Management of HydrationC1
Provide education to improve their hydration health literacyBhanu et al. 2019; Picetti et al., 2017
Individuals who are cognitively intact and physically capable can be taught to use the Drinks Diary to self-monitor their fluid intake.Jimoh et al., 2015C1
Assist to establish their fluid intake goal based on the calculated fluid recommendation.Volkert et al., 2018
Individuals who are cognitively intact and visually capable can be taught how to note changes in their level of hydration through the use of a color chart (See Appendix A.4 for description in full guideline), to compare to the color of their urine The chart is most accurate in individuals with better renal function.Armstrong et al., 1994, 1998;Mentes, Wakefield & Culp, 2006C1
   Fluid Regulation and documentation
Note: Frequency of documentation of fluid intake will vary from setting to setting and is dependent on an individual's condition.
Document a complete intake recording including hydration habitsMentes & IVANRC, 2000D
Create fluid volume list of each utensil to accurately calculate fluid consumptionBurns, 1992; Hart & Adamek, 1984C1
Authors

Dr. Mentes is Professor, University of California Los Angeles, Los Angeles, California; and Dr. Gaspar is Consultant, Chaska, Minnesota.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Janet C. Mentes, PhD, RN, FGSA, FAAN, Professor, University of California Los Angeles, 700 Tiverton Avenue, Los Angeles, CA 90095-6919; e-mail: jmentes@sonnet.ucla.edu.

Copyright © 2020 Csomay Center for Gerontological Excellence.

10.3928/00989134-20200108-03

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