Fall 2010

Defeating Dehydration — Patient Monitoring Is Key
By Maura Keller
Aging Well
Vol. 3 No. 4 P. 24

For most adults, dehydration is a problem with a quick fix: Grab a glass of water or a sports drink and you’re off. But for older adults, dehydration is the most common fluid and electrolyte problem and one that can have devastating long-term effects.

Identifying the Problem
Dehydration in the older adult population can occur for numerous reasons. “From a physiological standpoint, as aging occurs, the water content of our bodies decreases,” says Kelly O’Connor, RD, LDN, CDE, of Mercy Medical Center in Baltimore. “Research indicates the total body water content of a 75- to 80-year-old person is nearly 50% less than a young person. For some reason not yet clear, the decline in water content is even greater in elderly women.”

As O’Connor explains, people often rely on thirst as a signal for how much to drink. But at an advanced age, this may not be an accurate indicator of the body’s fluid needs. “Many older adults deliberately restrict their fluid or beverage intake if they are suffering from incontinence or are embarrassed about having to use the restroom many times a day,” O’Connor says. “They also may be confused and/or suffer from dementia and not be able to remember if they’ve consumed any beverages in a given day.” Also, older adults living alone at home or in nursing facilities may not have the mobility to get beverages by themselves and may be embarrassed to ask for help. What’s more, some medications may affect fluid status or intake, and healthcare professionals may be unaware that a patient’s fluid intake has declined.

“An older adult taking diuretic-type medication and not replacing the extra fluid lost also is at higher risk for dehydration,” O’Connor says. “They are more prone to flu and colds, both of which may cause fluid loss that is not easily replenishable.”

Signs and symptoms of dehydration in older adults include confusion and weakness, which are among the first symptoms to occur in severe dehydration. Other symptoms include dark urine, decreased skin elasticity, headache, dry mouth, fatigue and lethargy, a sudden change in blood pressure upon standing up, dizziness, and increased heart rate.

“Dehydration also can lead to compromised immune system, constipation, and even death since the organs are mostly water,” says Rebecca Scritchfield, MA, RD, LD,
 a nutrition and exercise expert specializing in healthy weight management. “Organs pull water from the brain, shrinking it and causing headaches. Chronic, persistent dehydration leads to cell death and, without proper rehydration, tissue death.”

If the population you are working with includes those with dementia or Alzheimer’s, who are normally confused or forgetful, extra diligence in monitoring for dehydration is necessary. For older adults, healthcare providers should remind them that fluids will decrease pain, keep them more alert, reduce constipation, and keep them out of the hospital.

“Chronic dehydration effects include kidney or heart damage, shortness of breath, pain, and tiredness,” says Jennifer Natt, RD, of Daughters of Israel Geriatric Center, a long-term care and rehabilitation facility in West Orange, N.J. “At Daughters of Israel, we introduce this to new employees at orientation and reinforce it at an annual nursing in-service. The key is prevention.”

Prevention Is Paramount
Healthcare providers may not have adequate knowledge of fluid requirements and the signs and symptoms of dehydration. That’s where education and ongoing diligence come in. “Healthcare providers should prompt older adults to drink between meals, especially with the cognitively impaired. They can offer beverages that the older adult enjoys,” Natt says. “Water should always be in reach throughout the day.” Also encourage fluid intake while brushing teeth, supervise during meals, and instruct family members and other older adult care providers about strategies to ensure proper fluid intake. Create a schedule for taking fluids, such as care planning. For example, an older adult at risk can drink a cup of a beverage every time he or she urinates.

Of course, preventing dehydration in older adults is the result of consistent monitoring. “A hydration protocol or regimen should be implemented for any older adults having a history of dehydration or assessed to be at high risk for dehydration,” O’Connor says. “Fluid intake and output may need to be tracked daily and recorded for comparison purposes.”

Regularly providing and offering beverages over the course of the day is also essential to preventing dehydration, and a variety of fluids should be offered at all meals, between meals, and at all medication administrations. Older adults also may need adaptive equipment, such as cups with handles, straws, or spouted cups in order to drink. Ensuring that these items are readily available may help increase their fluid intake.

Daughters of Israel has a hydration program with a variety of beverages and offers activities that include drinks in their programs. It’s also standard practice to include soups and seasonal fruits with high water content with meals, and for older adults to have a glass of water waiting in the dining room at each mealtime.

“If the staff gives the older adult a small cup of water with each medicine administration, the habit may be established that they need to drink a few ounces at each time,” O’Connor says. “Asking a resident or patient if they are thirsty and relying on them to gauge their own body’s need may not be an accurate way to ensure the resident gets adequate fluids.”

Dietitians recommend using the smaller “kid-size” bottles of water that older adults may carry around or keep by their beds or chairs. Offering smaller amounts often seems less overwhelming, and elders may be more apt to drink the smaller quantities than from a larger bottle of water.

Jo Anne Brown, RD, of Vi (formerly Classic Residence by Hyatt), a provider of senior living communities, says variety is key when it comes to enticing older adults to drink. “Change it up,” she says. “Put a little lemon in water to make it taste better. Try offering coffee, tea, and juice breaks.” Look for refreshing fluids that don’t jeopardize other medical concerns, such as those containing excessive calories, sugar, salt, and/or potassium. Make sure the fluids older adults consume work into a healthful diet and are readily available.

Scritchfield says flavored beverages can be more palatable than plain water and may encourage older adults to drink more. However, too much juice or sugary drinks may end up replacing calories that should come from food. “Fruit2O is a fruit-flavored, zero-calorie water beverage that is sugar free,” Scritchfield says. “If a senior is diabetic, it is particularly important that they don’t drink sugary beverages, so drinks like Fruit2O can be a great way to stay hydrated. Provide a variety of choices so the senior doesn’t get ‘drink fatigue.’ If they don’t want what’s available, they won’t drink, so find what works for them.”

RDs and other healthcare practitioners should keep in mind that many foods, particularly fruits and vegetables, have significant water content. Strive to include one or two of these foods at each meal to help increase fluid intake. Some examples include grapefruit, honeydew, strawberries, raw tomatoes, watermelon, raw celery, cooked asparagus, and raw or cooked broccoli.

O’Connor says RDs, as part of their nutritional assessments and evaluations, generally include a recommended daily fluid intake. “This information needs to be conveyed to all staff caring for any older adult (nurses, nurses’ aides, dietary staff, physicians, activities coordinators, etc), as all of these healthcare team members can help to ensure the older adult reaches their goal of having adequate fluid intake daily,” she says. There may be a need for some sort of checklist, whether it is used by staff members or the patient, to ensure that fluid status is consistently maintained as necessary.

“And remember, older adults don’t want to be a burden, so the best way to motivate them is to let them know they are not a burden and that you enjoy helping them stay healthy,” Scritchfield says. “You can also do thoughtful things like take them out to dinner or surprise them with fresh lemonade. Make it easy for them to say ‘yes’ to fluids.”

— Maura Keller is a Minneapolis-based writer and editor.