Research in Gerontological Nursing

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Original Research: Cross-Sectional Descriptive 

Dehydration Reduction in Community-Dwelling Older Adults: Perspectives of Community Health Care Providers

Lisa Abdallah, PhD, RN; Ruth Remington, PhD, GNP, ANP-BC; Susan Houde, PhD, ANP-BC; Lin Zhan, PhD, RN, FAAN; Karen Devereaux Melillo, PhD, GNP, ANP-BC, FAANP

Abstract

Dehydration is a common problem among older adults and can negatively affect their health. This crosssectional descriptive study used survey findings and focus group interviews to investigate dehydration problems among community-dwelling older adults and to identify strategies perceived to be helpful in preventing dehydration in this population. The survey sample (n = 18) and four focus groups (n = 36) included health care providers in the northeast United States from provider agencies representing emergency care, home care, primary care, and community health care. Survey findings indicated that 89% of participants identify dehydration as a problem affecting older adults, and 94% noted the need for a public campaign on dehydration awareness and reduction. Four major themes emerged: Intentional Avoidance and Caution, Lack of Awareness/Education/Understanding, Poor Access to Fluids, and Social and Environmental Influences. Strategies identified to promote hydration in community-dwelling older adults included community partnerships, community education, community engagement, and interdisciplinary approaches. This study provides useful information and detailed strategies recommended by health care providers for designing interventions to promote hydration for community-dwelling older adults.

Abstract

Dehydration is a common problem among older adults and can negatively affect their health. This crosssectional descriptive study used survey findings and focus group interviews to investigate dehydration problems among community-dwelling older adults and to identify strategies perceived to be helpful in preventing dehydration in this population. The survey sample (n = 18) and four focus groups (n = 36) included health care providers in the northeast United States from provider agencies representing emergency care, home care, primary care, and community health care. Survey findings indicated that 89% of participants identify dehydration as a problem affecting older adults, and 94% noted the need for a public campaign on dehydration awareness and reduction. Four major themes emerged: Intentional Avoidance and Caution, Lack of Awareness/Education/Understanding, Poor Access to Fluids, and Social and Environmental Influences. Strategies identified to promote hydration in community-dwelling older adults included community partnerships, community education, community engagement, and interdisciplinary approaches. This study provides useful information and detailed strategies recommended by health care providers for designing interventions to promote hydration for community-dwelling older adults.

Dehydration is a common fluid and electrolyte imbalance among older adults that negatively affects health and quality of life. Although there is no universal definition for dehydration, there are several proposed definitions. Dehydration has been defined as “the rapid weight loss of greater than 3% of body weight” as well as “a water/electrolyte disturbance arising from either a water depletion or a sodium depletion where there is an accompanying loss of water” (Joanna Briggs Institute, 2001, p. 1). Dehydration has been shown to be associated with increasing frailty and decline in cognitive functioning (Miller, Perry, & Morley, 1998; Palmisano-Mills, 2007; Voyer, McCusker, Cole, St-Jacques, & Khomenko, 2007; Warren et al., 1994). Risk factors for dehydration in the older adult population have been identified as lack of adequate fluid intake; complications associated with medications used to treat other comorbidities, such as antihypertensive and diuretic medications; physical and cognitive impairment; and exposure to excessive heat, which can be exacerbated in the summer months (Bennett, Thomas, & Riegel, 2004; Carroll, 2002; Kayser-Jones, 2000).

With increasing age, decline in kidney function results in the inability of the kidneys to concentrate the urine when decreased fluid intake occurs (Thomas, 2004). The decreased ability to concentrate urine places older adults at a higher risk for dehydration (Bossingham, Carnell, & Campbell, 2005; Sheehy, Perry, & Cromwell, 1999; Stookey, 2005). A decreased sensation of thirst is associated with aging and may also be a factor in the higher incidence of dehydration in this age group (Zembrzuski, 2004). Older adults have a decrease in lean body mass and an increase in the percentage of body fat, which also contribute to less total body water, thus placing the individual at an increased risk of dehydration if additional stresses occur (Bossingham et al., 2005; Sheehy et al., 1999). Dysphagia has also been shown to be a risk factor for dehydration (Kayser-Jones, 2000). Other risk factors include visual problems, decreased mobility due to functional problems, acute pathology, poor access to fluids, communication problems, failure of caregivers to provide fluids, and confusion (Ferry, 2005).

The Cost of Dehydration

Dehydration is one of the 10 most frequent diagnoses responsible for hospitalizations of older adults (Sheehy et al., 1999). In 1996, approximately 208,000 patients age 65 and older were hospitalized with a primary diagnosis of dehydration, which translated to an average cost of $6,539 per person hospitalized (National Center for Health Statistics, 1998). According to the National Hospital Discharge Survey (National Center for Health Statistics, 2004), 245,000 patients age 65 and older were hospitalized with a primary diagnosis of dehydration, contributing to further increases in the cost of hospital care for this population. The rate of hospitalizations for older adults with a principal diagnosis of dehydration increased by 40% between 1990 and 2000 (Kozak, Hall, & Owings, 2002; Xiao, Barber, & Campbell, 2004). In 1999, the cost of treating older adults in the United States with avoidable hospitalizations due to a primary diagnosis of dehydration was estimated to be $1.14 billion; this estimate did not include those who had a secondary diagnosis of dehydration (Xiao et al., 2004).

Of those hospitalized, it has been reported that 18% of older adults with dehydration died within 30 days, and nearly 31% died within the year (Bennett, 2000; Kobriger, 1999). Many others are hospitalized with primary diagnoses that may be precipitated by poor hydration status, such as confusion, constipation, respiratory infections, and urinary tract infections (Palmisano-Mills, 2007; Voyer et al., 2007). As many as 1 million older adults are admitted to acute care settings per year with dehydration as a factor in their clinical presentation (Sansevero, 1997).

Older adults with dehydration are at risk for increased mortality (Mentes, 2006b), up to seven times that of older adults who are not dehydrated (Bennett et al., 2004). Hospitalization with dehydration has nearly three times the mortality of hip fracture at 30 days and two times the mortality at 1 year (Warren et al., 1994). The costs to treat older adults who are admitted to health care facilities with complications related to dehydration are high.

Literature Review

It is thought that dehydration is common in both nursing home and community settings and that the primary risk factor is poor fluid intake (Bennett, 2000). Research has supported that nursing home residents have higher rates of dehydration than community-dwelling older adults (Kamel, Karcic, Karcic, & Barghouti, 2000). One study found that nursing home residents who were regularly prompted to drink more fluids increased their fluid intake. This finding was more notable for those with greater cognitive impairment. For those with a milder level of cognitive impairment, consideration of the choice of fluid had a greater impact than prompting alone (Simmons, Alessi, & Schnelle, 2001). Increases in fluid intake were small, however, and the fluid intake was considered inadequate, with the older adults remaining at risk for dehydration. The study presents important suggestions that should be tested in the community environment to determine the impact on fluid intake.

In an integrative review of the literature exploring dehydration, Hodgkinson, Evans, and Wood (2003) concluded that most of the research studies reviewed had weaknesses in research design and data reporting and used nonrandomized or observational methodology. The review supported a need for higher quality research related to risk factors and assessment tools for dehydration and/or hydration status. They found no evidence to support gender as a risk factor for dehydration and concluded that semiindependent older adults may be at highest risk for dehydration because although they appear capable of obtaining fluids, they are not. Incontinence, although not a risk factor for dehydration, was found to be a risk factor for lower fluid intake.

In one study, 48% of the older adults visiting an emergency department were found to have chronic dehydration according to blood values (Bennett et al., 2004). Sixty-five percent of those from residential facilities were dehydrated, while 44% of those residing in the community were dehydrated (Bennett et al., 2004). However, little research has been done to explore dehydration in the community. Older adults in the community with emotional or physical health concerns may be at increased risk for dehydration (Bennett et al., 2004).

Characteristics of Dehydration

The most common signs of dehydration include weight loss, confusion, dry mucous membranes, constipation, and orthostatic hypotension (Bennett, 2000). The signs of dehydration in older adults may be difficult to interpret, however, because these signs may be due to factors other than dehydration (Bennett, 2000). For example, medications may cause mouth dryness, orthostatic hypotension, or constipation, and weight loss may be due to a number of health problems other than poor hydration. The signs and symptoms of dehydration are also likely to be less pronounced in older adults, so consideration of risk factors is very important in prevention (Archibald, 2006). Mental status changes may result from dehydration, but there are many causes of confusion that need to be considered, including respiratory or urinary tract infection or drug toxicity (Larson, 2003). There are limited data that define the pathophysiology and cellular mechanisms underlying the cognitive effects of dehydration (Wilson & Morley, 2003).

Purpose

The purpose of this study, entitled Dehydration Reduction in the Community (DRINC), was to explore health care providers’ perceived risk factors regarding dehydration and their proposed strategies to promote hydration for community-dwelling older adults. Based on identified factors and observed phenomena, future interventions will be designed to promote quality hydration care for community-dwelling elderly individuals.

Method

Procedure

After the study was approved by the University Institutional Review Board, a seven-item assessment survey (Figure 1) was mailed to nursing administrators of hospitals, home care agencies, community health centers, and a selection of primary care practices (N = 39) in the Greater Lawrence and Lowell areas of Massachusetts. Health care agencies in these regions were chosen primarily because they service urban neighborhoods composed of a highly diverse population of older adults. In addition, the agencies chosen were in close proximity to the researchers’ university, allowing for the development of potential future collaborations related to hydration promotion. Survey recipients were asked to complete the survey or delegate it to the appropriate person at their agency. Key representatives from these settings were asked to identify what they believed to be the extent of the problem of dehydration among the older adults in their service area and what the most effective strategies for resolution might be.

Survey Mailed to Nursing Administrators of Hospitals, Home Care Agencies, Community Health Centers, and a Selection of Primary Care Practices as Part of the Dehydration Reduction in the Community (DRINC) Study.

Figure 1. Survey Mailed to Nursing Administrators of Hospitals, Home Care Agencies, Community Health Centers, and a Selection of Primary Care Practices as Part of the Dehydration Reduction in the Community (DRINC) Study.

Participants

Eighteen of the 39 surveys mailed were completed and returned for a 46% response rate. No specific attempt was made to recontact those agencies that did not respond to the initial mailed survey. In addition, all representatives from these agencies were invited to attend a 1-hour focus group interview to share their perspectives about the dehydration issue (Figure 2) and to discuss strategies for dehydration reduction in the community. Staff from four provider agencies indicated their interest in participating in a focus group interview. Four 1-hour focus groups (representing 10% of the target sample) were scheduled and held at each of the four responding provider agencies between January and April 2007.

Focus Group Questions Used as Part of the Dehydration Reduction in the Community (DRINC) Study to Address the Issue of Dehydration and Strategies to Reduce It in the Community.

Figure 2. Focus Group Questions Used as Part of the Dehydration Reduction in the Community (DRINC) Study to Address the Issue of Dehydration and Strategies to Reduce It in the Community.

The focus group interviews included 36 health care providers from agencies representing emergency care (n = 5), senior support service organization (n = 6), home care (n = 8), and community health care (n = 17). The health care providers who participated in each of the four focus groups included primary care providers, RNs, physical therapists, home care assistants, and a speech therapist. Focus group interviews were audio recorded and subsequently transcribed verbatim, and field notes were taken by a facilitator (Côte-Arsenault & Morrison-Beedy, 1999). Focus group participants in three groups were each given a $25 gratuity for agreeing to participate outside their work hours. One provider agency held the focus group during participants’ scheduled work hours, and refreshments were provided in lieu of the $25 gratuity.

Data Analysis

Mailed survey data were analyzed, and frequencies of participant responses were calculated. In addition, comments from the open-ended questions on the surveys were content analyzed, and major themes were identified (Weber, 1990). The audio recordings of the focus group interviews were transcribed verbatim into Microsoft Word documents. Narrative contents including the field notes were coded and analyzed. Each investigator conducted an independent content analysis, and the results were then compared and contrasted among the five investigators. Group consensus was reached for common themes, key descriptions, and variations (Weber, 1990).

Findings

Mailed Survey

The survey revealed that 89% of the participants reported dehydration to be a problem affecting older adults, and 94% of participants believed the older adult community would benefit from a public media campaign on dehydration awareness and reduction. The participants identified major factors associated with dehydration in communitydwelling older adults (Table).

Factors Leading to Dehydration in Community-Dwelling Older Adults, as Identified by Survey Participants

Table: Factors Leading to Dehydration in Community-Dwelling Older Adults, as Identified by Survey Participants

On the mailed survey, participants agreed that awareness and education about risks of dehydration were necessary in helping to alleviate this problem for the older adults in their area and that the best way to promote public awareness would be to use mass media, such as radio, television, and educational pamphlets that could be distributed at housing projects and senior centers and by health care providers.

Focus Groups

Content analysis revealed four major themes in this study associated with dehydration in community-dwelling older adults:

  • Intentional Avoidance and Caution.
  • Lack of Awareness/Education/Understanding.
  • Poor Access to Fluids.
  • Social and Environmental Influences.

Intentional Avoidance and Caution. The participants noted that the older adults they worked with feared that increased fluid intake would precipitate fluid overload (especially if they were on diuretic therapy), incontinence episodes (especially if they had a history of a weak bladder and poor mobility), and falls (particularly in those with difficulty ambulating). The following participant quotations provide examples on various issues:

  • Fluid overload. “I think it is that fear of, I am on a diuretic because...I’m taking on too much fluid...so I am not going to drink because I am going to put too much fluid in my body.... So they don’t drink and then they become dehydrated because of the diuretic.”
  • Incontinence. “I see that a lot…. They almost watch what they take in because they know it has to come out.”
  • Fear of falling. “Like high-fall risks.... They are afraid to get up and go to the bathroom, so they don’t drink as much.… They are afraid of going back and forth if there is no one there to help them. I see people not drinking as much fluid as they should because they don’t want to have to go to the bathroom.”

An additional factor related to Intentional Avoidance and Caution identified by the focus group participants was the older adults’ dislike of the taste of water, as exemplified by the following remarks:

  • “I have an image as a teenage waitress and of elderly ordering a hamburger and a cup of coffee.” (Implying that older adults dislike water).
  • “The elderly are at the senior centers all day from 9 a.m. on, playing cards, Bingo, through lunch, and all they have available is a pot of coffee.”
  • “Everyone has bottled water [now] and that really wasn’t the case [for these older adults]. I can recall that from my grandmother. I mean all she drank was tea, she drank, maybe a glass of water in the morning, and she was very healthy, but she never drank water.”

Participants from the community health clinic primarily serving a Southeast Asian population noted the community members’ “fear of the drinking water being contaminated” (especially in the Cambodian population), stating, “I actually think that the community has a fear of the water…. Well, they grew up in Cambodia where water was dirty…you know, drinking bottled water is the best.”

In addition, participants believed some older adults were overwhelmed with the recommended eight glasses of water per day. The following statements highlight participants’ concerns about their patients drinking enough:

  • “I have a lot of elderly patients that…have ... some of the signs of dehydration, and it is a struggle for them to drink, like I have to...you know, take a water bottle and put it on the table, if it’s in their vision then it will remind them to drink. Otherwise, that’s just not in their lifestyle.”
  • “It’s funny, as I’m thinking, I just spoke with somebody the other day and was asking them about their hydration and to them, ‘Well, I take pills three times a day.’ That’s when they drink their water so that was it.”

Lack of Awareness/Education/Understanding. The study participants were greatly concerned with the lack of awareness and understanding of the risks of dehydration in the community-dwelling older adults and their families. As they noted, the older adults they work with may not be aware of the risks involved in dehydration or understand given instructions for fluid intake. Additionally, some older adults have cognitive impairment or depression, which hindered them from understanding instructions for hydration. Of equal concern was a lack of education or accurate instruction about dehydration to older adults in the community.

As noted, dehydration occurred when the older adult (and his or her family):

  • Lacked awareness of what kinds of fluids and how much to drink.
  • Were unaware of the dehydrating effects of alcohol and many medications.
  • Lacked the sensation of thirst.
  • Were unaware that when one sweats, the body is losing water.

Example comments included:

  • “I think lack of thirst is one thing…. In the population that has dementia, then obviously it is a cognitive lack of understanding, and then…lack of education—that people aren’t aware of how much fluid they need in order to maintain a healthy, you know, maintenance of the body.”
  • “There is a lack of education due to the overburdened system. There is no time to teach.”
  • “They don’t show up in the ER until they are ‘kissing the angels,’ they are so dehydrated.”
  • “You know, I think we do see a lot of elderly, like her mom [another participant’s mother] was in the hospital two or three times for dehydration. They are not really aware of…the problem.”

Poor Access to Fluids. The third theme was related to poor access to fluid. The most commonly stated reasons were living alone, having difficulty with mobility, and frailty and illness, which limited the older adults’ ability to frequently access fluids. Living on a fixed income and having difficulty purchasing bottled water and other fluid sources were cited as barriers to accessing fluids. In addition, being homeless and abusing substances (e.g., alcohol, illicit drugs) were seen as precipitating factors to older adults’ having difficulty accessing fluids. As one participant noted:

I think actually it’s a combination, in my mind, of all of the above. They are home alone. They have no family that comes over. They are probably depressed. They have no way of getting to the refrigerator or even the sink to get something to drink because they are physically challenged. They are on medications, diuretics and what not…and they don’t want to be incontinent…. I think really it’s just a combination of everything.… They don’t want anything to drink, you know. Or, no one is coming over to see me, why should I drink—that type of thing.

Social and Environmental Influences. Social and environmental influences of dehydration were identified. Two major seasonal factors were brought forth. First, the drying effect of heating systems during winter months in conjunction with influenza outbreaks precipitated dehydration incidence in community-dwelling older adults. Second, concerns were expressed that older adults’ exposure to increased temperatures in the summer months led to dehydration.

Social and cultural influences related to the above were also described by participants. Comments by health care providers caring for Southeast Asian patients included:

  • “Most elders born in Cambodia…with the hot country… a hot climate… And so, people rely on the temperature and ‘I’m hot now and I’m thirsty’,...but because the body is made in Cambodia [accustomed to the Cambodian climate], and they live here with the cold weather in winter and air conditioning or electric fans in summer, they do not feel like they are thirsty…so they don’t drink.”
  • “Sometimes it’s hard for them to turn the air conditioning on, and sometimes in the house, air conditioners are very high in the ceiling and they have to call their neighbors to adjust it.... They are always cold, so they don’t feel the heat.”

Moreover, social conditions such as living alone and a lack of family or other social supports were also identified as risk factors of dehydration.

Strategies to Promote Hydration in Community-Dwelling Older Adults

Participants in this study proposed several strategies for promoting hydration in community-dwelling older adults. A major overarching theme related to promotion of hydration was to Educate and Make Aware. Education of older adults, their families, and home care providers (e.g., paraprofessional staff) on a regular basis was noted as a key facilitating strategy to promote hydration. Direct interventions to promote increased fluid intake and reduce risks of dehydration can be implemented at the point of care with the older adult and his or her family members. Mass outreach is needed to increase public awareness of the risks involved in dehydration and to promote hydration for older adults in the community.

Direct Interventions to Promote Fluid Intake

Recommendations for promotion of adequate fluids for older adults through direct intervention included:

  • Providing easy access to fluids by placing containers such as sport bottles, sippy cups, and small bottles of spring water or flavored water within their reach, especially if they have limited mobility in the home.
  • Having visitors (family) or care providers (home care staff) encourage and remind older adults to drink.
  • Educating older adults about hydrating foods that could be substituted for water, such as popsicles, juice, Italian ice, sherbet, gelatin desserts, and pudding, if they dislike the taste of water.
  • Providing Meals on Wheels programs with bottled water that includes catchy slogans about the importance of hydration.

A key factor identified by participants regarding the success of direct interventions to improve fluid intake was through education of the family and/or formal caregivers. As one participant said:

I think the family is very, very important, especially if they are involved.… In some of our populations we have very involved families, so obviously that’s where the education ought to be but…the other half of that population that we serve…the most important people going in there would be the formal support of homemakers and home health aides,…and one thing we can do, as a group, is to make sure our care plans for the paraprofessionals stress the importance of fluids. Offer fluids every time you come in…you know, encourage fluids…that kind of thing.

Primary Care and Nursing Staff Education at Point of Care

Strategies proposed about the promotion of hydration and prevention of dehydration by primary care providers and nurses included:

  • Providing education about hydration with discharge instructions after emergency department visits and hospital stays.
  • Promoting education as part of the older adult’s physical examination by the primary care provider.
  • Having nurses provide education through automatic telephone follow up and outreach education to patients admitted with a diagnosis of dehydration.
  • Providing education through pharmacists’ directions on medication bottles, to encourage older adults to take fluids with their medications (if not contraindicated).
  • Hiring nurses to provide education about hydration, along with other disease management strategies in primary care offices.

Mass Awareness Strategies to Promote Hydration in Older Adults

Detailed strategies were suggested to educate the community about dehydration and the importance of hydration in older adults. Reaching out to the community as a whole to increase awareness about the importance of hydration in older adults will help promote hydration for this population. Eyecatching brochures and posters can be distributed to senior centers, parishes, temples, housing projects, and adult day centers, as well as at places and events with a high concentration of older adults, such as grocery stores, flu clinics, blood pressure clinics, parish nursing activities, and food centers.

Mass outreach was also suggested through the development of public awareness announcements that could run on the local television and radio stations and in newspapers. Funding could be sought from organizations (e.g., AARP, HMOs) that promote quality care for older adults or distributors of water and other hydrating drinks. In addition, nurses can play a major role in promotion of hydration in older adults by providing educational programs for the community through local hospital community outreach, senior centers, public health departments, and primary care offices.

Discussion

Health care providers in this study identified major risk factors related to dehydration and provided strategies that nurses can use as they work with formal and informal caregivers to provide quality care to community-dwelling older adults. Family members and formal care providers can be instrumental in making fluids readily available to older adults. It is recommended that half the daily fluid intake be water, although milk, vegetable and fruit juices, and soup may also be included as fluid intake (Bennett, 2000). In a study of nursing home residents, researchers found that providing fluids requested by the residents increased their fluid intake (Simmons et al., 2001). Providing fluids such as caffeinated beverages and carbonated drinks was occasionally also considered appropriate.

Focus group participants in this study supported offering a wide variety of beverages to older adults to promote hydration, especially where it was noted that some older adults dislike water. However, one must be mindful that minimum fluid intake, as well as significant intakes of caffeinated beverages (e.g., carbonated beverages, coffee, tea) and alcoholic beverages may have a diuretic effect and can lead to fluid loss (Davidhizar, Dunn, & Hart, 2004).

It is recommended that adults older than age 70 consume eight glasses of water daily (Russell, Rasmussen, & Lichtenstein, 1999). However, the health care providers in this study believed that recommending eight glasses of water per day was seen as overwhelming by many older adults and suggested a strategy whereby older adults were instead encouraged to gradually increase their fluid intake. This approach seems to be supported by the findings of Lindeman et al. (2000), who found no strong evidence to support the eight glasses per day recommendation of fluid intake for older adults. In a study that examined the fluid intake of 796 community-dwelling older adults, no statistically significant differences were found in sodium level, blood urea nitrogen, creatinine, blood pressure, constipation, or fatigue between older adults who drank three to five glasses per day (n = 207) and those who drank six or more glasses per day (n = 569) (Lindeman et al., 2000). The researchers suggested that older adults should be encouraged to consume an amount that is comfortable for them.

Environmental issues were described by the study participants as important factors in preventing dehydration. Heat, dryness from heating systems in winter, and hot rooms were considered to be environmental factors contributing to dehydration in community-dwelling older adults. This finding has been supported in the literature. Providing fluids to replace those lost in high temperatures is advocated (Davidhizar et al., 2004).

In a study of nursing home residents, four basic kinds of individuals with hydration problems were identified, which may also have relevance for older adults in the community (Mentes, 2006a). The first involves those older adults who can drink and may either be independent in drinking but are not aware of the amount of fluids that are needed to prevent dehydration, or are forgetful and not able to drink an adequate amount of fluids. The second kind involves those who cannot drink and may have either dysphagia or be physically dependent for hydration. The third group consists of older adults who will not drink because they either fear incontinence or they have never consumed many liquids. The fourth group is the terminally ill group. The group that would not drink had the highest incidence of dehydration throughout the study.

Interventions may need to be tailored to address the individual needs of each group on the basis of the characteristics of the hydration problem (Mentes, 2006a). The findings from this study may enhance the development of a community awareness and education program to promote hydration.

The participants in this study noted that dehydration can be prevented with the assistance of appropriate education and awareness. Once again, this is a key area for nursing intervention. Nurses frequently find themselves in the role of case manager and/or care coordinator for many community-dwelling older adults in their care. By implementing a plan to decrease the incidence of dehydration among this population, nurses may also decrease the cost of care and improve the overall quality of life for the older adult.

Mentes (2006b) stressed the importance of educating the family about the importance of fluid intake to prevent dehydration and about the risk factors for dehydration. Education regarding the most important fluids and recommendations about the quantity of daily fluid intake to prevent dehydration is important for staff, family, and older adults. Families should also consider reporting to their primary care provider the failure of their family member to eat or drink adequately, so appropriate assessment and intervention can occur prior to the onset of dehydration and its serious health consequences (Mentes, 2006b). Educating older adults, their families, and home care providers (e.g., paraprofessional staff) on a regular basis about dehydration, risk factors associated with it, and ways to prevent it were noted by the study participants to be key in the promotion of hydration, therefore lending further support to strategies discussed in the literature (Bennett, 2000; Bennett et al., 2004; Ferry, 2005; Mentes, 2006b; Mentes & Iowa Veterans Affairs Research Consortium, 2000).

Limitations

Environmental and cultural practices in the geographical area studied may have influenced the results. The mailed survey findings were representative of 46% of the target sample, and the focus group findings represented 10% of the target sample, therefore limiting the generalizability of the perceptions of the health care providers in this study.

Conclusion

The findings of this study shed further light on the risk factors perceived to be associated with dehydration from the perspective of health care providers who work with older adults. Using both survey findings and focus group interviews, four major themes emerged: Intentional Avoidance and Caution, Lack of Awareness/Education/Understanding, Poor Access to Fluids, and Social and Environmental Influences. Development of strategies to promote hydration in community-dwelling older adults through community partnerships, community education, community engagement, and interdisciplinary approaches are essential. Nurses can play a major role in the prevention of dehydration and promotion of hydration in this population by incorporating the strategies identified. Further nursing research is needed to evaluate the effects of intervention strategies on the promotion of hydration among community-dwelling older adults. In addition, research that explores the perceptions of these older adults regarding dehydration—with a focus on those from diverse cultural backgrounds to explore cultural factors in dehydration or hydration promotion—should be considered.

References

  • Archibald, C2006. Promoting hydration in patients with dementia in healthcare settings. Nursing Standard, 20(44),49–52.
  • Bennett, JA2000. Dehydration: Hazards and benefits. Geriatric Nursing, 21, 84–87. doi:10.1067/mgn.2000.107135 [CrossRef]
  • Bennett, JA, Thomas, V & Riegel, B2004. Unrecognized chronic dehydration in older adults: Examining prevalence rates and risk factors. Journal of Gerontological Nursing, 30(11),22–28.
  • Bossingham, MJ, Carnell, NS & Campbell, WW2005. Water balance, hydration status, and fat-free mass hydration in younger and older adults. American Journal of Clinical Nutrition, 81, 1342–1350.
  • Carroll, P2002. The heat is on: Protecting your patients from nature’s silent killer. Home Healthcare Nurse, 20, 376–385.
  • Côte-Arsenault, D & Morrison-Beedy, D1999. Practical advice for planning and conducting focus groups. Nursing Research, 48, 280–283. doi:10.1097/00006199-199909000-00009 [CrossRef]
  • Davidhizar, R, Dunn, CL & Hart, AN2004. A review of the literature on how important water is to the world’s elderly population. International Nursing Review, 51, 159–166. doi:10.1111/j.1466-7657.2004.00224.x [CrossRef]
  • Ferry, M2005. Strategies for ensuring good hydration in the elderly. Nutrition Reviews, 63(6 Part 2),S22–S29. doi:10.1111/j.1753-4887.2005.tb00151.x [CrossRef]
  • Hodgkinson, B, Evans, D & Wood, J2003. Maintaining oral hydration in older adults: A systematic review. International Journal of Nursing Practice, 9(3),S19–S28. doi:10.1046/j.1440-172X.2003.00425.x [CrossRef]
  • Joanna Briggs Institute. 2001. Maintaining oral hydration in older people. Best Practice, 5(1). Retrieved October 24, 2008, from http://www.joannabriggs.edu.au/pdf/BPISEng_5_1.pdf
  • Kamel, HK, Karcic, E, Karcic, A & Barghouti, H2000. Nutritional status of hospitalized elderly: Differences between nursing home patients and community-dwelling patients. Annals of Long-Term Care, 8(3),33–38.
  • Kayser-Jones, J2000. Improving the nutritional care of nursing home residents. Nursing Homes, 29(10),56–59.
  • Kobriger, AM1999. Dehydration: Stopping a “sentinel event.”Nursing Homes, 48(10),60–65.
  • Kozak, LJ, Hall, MJ & Owings, MF2002. National Hospital Discharge Survey: 2000 annual summary with detailed diagnosis and procedure data. Vital and Health Statistics, 13(153),1–194.
  • Larson, K2003. Fluid balance in the elderly: Assessment and intervention —Important in community health and home care nursing. Geriatric Nursing, 24, 306–309. doi:10.1016/S0197-4572(03)00247-7 [CrossRef]
  • Lindeman, RD, Romero, LJ, Liang, HC, Baumgartner, RN, Koehler, KM & Garry, PJ2000. Do elderly persons need to be encouraged to drink more fluids?Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 55, M361–M365.
  • Mentes, JC2006a. A typology of oral hydration problems exhibited by frail nursing home residents. Journal of Gerontological Nursing, 32(1),13–19.
  • Mentes, JC2006b. Oral hydration in older adults: Greater awareness is needed in preventing, recognizing, and treating dehydration. American Journal of Nursing, 106(6),40–49.
  • Mentes, JCIowa, Veterans Affairs Research Consortium2000. Hydration management protocol. Journal of Gerontological Nursing, 26(10),6–15.
  • Miller, DK, Perry, HM & Morley, JE1998. Relationship of dehydration and chronic renal insufficiency with function and cognitive status in older US blacks. In Vellas, B, Albarede, JL & Garry, PJ (Eds.), Hydration and aging: Facts, research and intervention in research (pp. 149–159). New York: Springer.
  • National Center for Health Statistics. 1998. Health, United States, 1998 (Publication No. PHS 98–1232). Retrieved October 24, 2008, from http://www.cdc.gov/nchs/data/hus/hus98.pdf
  • National Center for Health Statistics. 2004. National Hospital Discharge Survey. Retrieved October 29, 2007, from ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Datasets/NHDS/
  • Palmisano-Mills, C2007. Common problems in hospitalized older adults: Four programs to improve care. Journal of Gerontological Nursing, 33(1),48–54.
  • Russell, RM, Rasmussen, H & Lichtenstein, AH1999. Modified food guide pyramid for people over seventy years of age. Journal of Nutrition, 129, 751–753.
  • Sansevero, AC1997. Dehydration in the elderly: Strategies for prevention and management. Nurse Practitioner, 22(4), 41–42, 51–57, 63–66.
  • Sheehy, CM, Perry, PA & Cromwell, SL1999. Dehydration: Biological considerations, age-related changes, and risk factors in older adults. Biological Research for Nursing, 1, 30–37. doi:10.1177/109980049900100105 [CrossRef]
  • Simmons, SF, Alessi, C & Schnelle, JF2001. 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]
  • Stookey, JD2005. High prevalence of plasma hypertonicity among community-dwelling older adults: Results from NHANES III. Journal of the American Dietetic Association, 105, 1231–1239. doi:10.1016/j.jada.2005.05.003 [CrossRef]
  • Thomas, DR2004. Dehydration in older adults. Nutrition and the MD, 30(11),1–4.
  • Voyer, P, McCusker, J, Cole, M, St-Jacques, S & Khomenko, L2007. Factors associated with delirium severity among older patients. Journal of Clinical Nursing, 16, 819–831. doi:10.1111/j.1365-2702.2006.01808.x [CrossRef]
  • Warren, JL, Bacon, WE, Harris, T, McBean, AM, Foley, DJ & Phillips, C1994. The burden and outcomes associated with dehydration among US elderly. American Journal of Public Health, 84, 1265–1269. doi:10.2105/AJPH.84.8.1265 [CrossRef]
  • Weber, RP1990. Basic content analysis (2nd ed) Newbury Park, CA: Sage.
  • Wilson, MG & Morley, JE2003. Impaired cognitive function and mental performance in mild dehydration. European Journal of Clinical Nutrition, 57(Suppl. 2),S24–S29. doi:10.1038/sj.ejcn.1601898 [CrossRef]
  • Xiao, H, Barber, J & Campbell, E2004. Economic burden of dehydration among hospitalized elderly patients. American Journal of Health-System Pharmacy, 61, 2534–2540.
  • Zembrzuski, C2004. Nutrition and hydration. MEDSURG Nursing, 13, 60–61.

Factors Leading to Dehydration in Community-Dwelling Older Adults, as Identified by Survey Participants

Lack of awareness

Lack of thirst

Lack of taste buds necessary to enhance the desire to drink

Psychological issues (e.g., depression, dementia)

Incontinence (i.e., The less they drink, the fewer embarrassing “accidents” they have to deal with.)

Lack of recognition that they may be dehydrated because of decreased thirst mechanism

Lack of knowledge

Lack of resources (e.g., financial constraints, inability to access fluids, no social supports)

Other health or physical limitations (e.g., fatigue, diuretic therapy)

Multiple mechanisms (e.g., poor mobility, lack of bladder control, lack of understanding the importance of fluids)

Confusion

Use of diuretic medication with continued need for hydration

Authors

Dr. Abdallah is Assistant Professor, Dr. Remington is Associate Professor, Dr. Houde is Professor and Director of the Master’s Program, Dr. Melillo is Professor and Chair, Department of Nursing, School of Health and Environment, University of Massachusetts Lowell, Lowell, Massachusetts, and Dr. Zhan is Dean and Professor, School of Nursing, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts.

This study was funded by the University of Massachusetts Lowell, Office of Research Administration.

Address correspondence to Lisa Abdallah, PhD, RN, Assistant Professor, Department of Nursing, School of Health and Environment, University of Massachusetts Lowell, 3 Solomont Way, Suite 2, Lowell, MA 01854-5126; e-mail: lisa_abdallah@uml.edu.

10.3928/19404921-20090101-01

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