D
Dehydration in Older Adults
Leilani Feliciano and Madeline R. Lag
University of Colorado, Colorado Springs,
Colorado Springs, CO, USA
Synonyms
Fluid deficit; Fluid imbalance; Insufficient fluid
intake
Definition
Dehydration refers to a decreased amount of water
in the body as a result of inadequate fluid
intake (Natural Hydration Council 2019).
Overview
Dehydration is one of the leading causes of hospitalization in older adult populations. Sufficient
hydration is essential to maintain good health, as
water is necessary for absorption of nutrients,
regulating body temperature, and physical and
mental performance (Kleiner 1999). Dehydration
can thus lead to a host of health problems including constipation, urinary tract infection (UTI),
delirium, mental and functional decline, and
increased morbidity and mortality (Bratlund et al.
2010; Chidester and Spangler 1997; Sanservo
1997; Silver 1990; Weinberg and Minaker 1995).
Dehydration is also associated with negative emotion states such as irritability, anger, hostility, and
depressed mood (Liska et al. 2019). In addition,
the prevalence of dehydration among older adults
serves as a tremendous financial burden to the
healthcare system, with hospitalizations for dehydration and associated complications of dehydration costing millions of dollars yearly (Kim 2007;
Warren et al. 1994).
Older adults are particularly at risk for dehydration because of physiological changes associated with aging including decreased muscle to fat
ratio, reduction in total body water, and decreased
thirst perception (Ferry 2005; Masot et al. 2018).
As a result of age-related changes, older adults
face unique barriers to hydration management.
For example, functional barriers including
compromised mobility, sensory deficits, arthritis,
and decreased grip strength may indirectly contribute to dehydration in older adults by making it
more difficult for the older person to access
healthy beverages (Feliciano 2005). Older adults
with comorbid illnesses such as chronic pain,
diabetes, and depression may take medications
that contribute to dehydration (Ferry 2005; Goldberg et al. 2014), as well, placing them at
increased risk for adverse events and complicated
the management of dehydration is this population.
Identifying dehydration in older adults is challenging. Detection is frequently accomplished in
hospitals and residential care settings. Blood tests
and urinalyses are the typical means of detection.
© Springer Nature Switzerland AG 2019
D. Gu, M. E. Dupre (eds.), Encyclopedia of Gerontology and Population Aging,
https://doi.org/10.1007/978-3-319-69892-2_808-1
2
However, home detection is much more difficult
given the lack of simple home testing kits and
efforts may need to be placed in the areas of
psychoeducation and prevention (Feliciano
2005). Behavioral interventions have been
implemented in the homes of older adults using
individually tailored treatment to manage dehydration, and these will be discussed in more detail
in the next sections.
Key Research Findings
Risk
Several factors contribute to the risk and development of dehydration in older adults. These factors
can be grouped in terms of age-related physical,
functional, and complicating factors. In terms of
physical factors, decreased muscle mass and loss
of bone density with age are big contributors, as
the muscle and bone compromise 73% of total
body water (Ferry 2005; Lavizzo-Mourey 1987).
Reduced renal functioning also can result in lower
levels of water in the body as the kidneys secrete
less renin, an enzyme that signals thirst (Begg
2017; Sanservo 1997). Increased body mass
index (BMI) is also associated with lower levels
of total body water. Ritz and colleagues discuss
the reasons for this including that “Since fat free
mass contains most of body water, as BMI
increases weight is made of a greater proportion
of fat, a lower fat free mass, hence a lower body
water” (Ritz et al. 2008, p. 743). Given that older
adults have decreased muscle mass, those who are
obese are at an increased risk for dehydration.
In terms of functional factors, comorbid physical conditions such as arthritis can decrease the
accessibility of water, as older adults may have
difficulty opening containers, walking, or properly holding beverages (Sanservo 1997). Older
adults with incontinence, or loss of bladder control, may limit their fluid intake to avoid frequent
trips to the bathroom or having accidents in public
(Simmons et al. 2001). Other comorbid conditions
including dysphagia (i.e., difficulty swallowing),
pain, and fatigue can make water difficult or painful to drink (Bratlund et al. 2010).
Dehydration in Older Adults
Complicating factors include age-associated
conditions such as cognitive impairment. Older
adults living with neurocognitive disorder
(dementia or memory impairment) may have difficulties remembering to drink water (Masot et al.
2018). Cognitive impairment, particularly language difficulties, can also make it difficult for
older adults to communicate their needs such as
thirst (Miller 2015). Misperceptions of thirst cues
as hunger or stomach pain may also interrupt
proper hydration.
Other physical factors such as deteriorating
oral health such as sore gums or the presence of
dentures may complicate proper hydration as they
can decrease taste sensation and prevent adequate
fluid intake (Miller 2015). Moreover, sensory
changes in older adulthood can also serve as barriers to hydration; poor vision can make it difficult
to locate or access fluids, and reduced olfaction
can result in lack of appetite or perceived thirst
(Blair 1990; Masot et al. 2018).
Another complicating factor relates to the
number and type of medications that many (if
not most) older adults take. For example, older
adults are often prescribed medications with
dehydrating side effects such as diuretics, laxatives, and sedatives (Belsky 1999; Masot et al.
2018). Lastly, personal factors, such as preferences for non-hydrating beverages (e.g., coffee,
tea) over hydrating beverages (e.g., water), also
complicate the picture, as caffeinated beverages
serve as bladder irritants and cause one to urinate
more, contributing to less fluid in the system overall (Feliciano 2005).
Barriers to Hydration Management
There are several barriers to managing proper
hydration. First, signs of dehydration in younger
adults cannot be as easily identified in older
adults. For example, decreased skin elasticity (i.
e., skin turgor) and dry mouth are more common
in older adults and are thus not adequate indicators
of dehydration (Feliciano 2005). Unfortunately,
few tests for assessing hydration levels can be
conducted in an individual’s home (Feliciano
et al. 2010).
Older adults living alone at home may be more
prone to dehydration than older adults living in
Dehydration in Older Adults
institutional care, as they may have inadequate
nutrition and be less physically active, which can
lead to decreased muscle mass and increased risk
for dehydration (Leibovitz et al. 2007). As a result
of the lack of available measures for the general
public, older adults may be misdiagnosed as having other medical concerns (e.g., dementia, delirium) or will not be identified until the need to visit
a hospital occurs (e.g., after a fall) where they may
be tested for dehydration.
Second, healthcare providers may make inaccurate assessments of older adults’ hydration
needs. Although a common prescription is that
adults should consume at least 64 ounces of
water (8, 8 oz glasses) through food and beverages
each day, the reasoning for such a recommendation does not have a clear scientific basis
(Feliciano 2005; Valtin 2002). The World Health
Organization (WHO) recommends that older
adult women consume 2.2 liters (74 oz) of water
each day and older adult men consume 2.9 l (98
oz) of water each day (World Health Organization
2009). The necessary amount of water intake is
likely somewhere within this range of
recommended values and varies by an individual’s gender, age, weight, and activity level
(Chidester and Spangler 1997; Ferry 2005; Ritz
et al. 2008). Environmental conditions also come
into play, as those older adults living in hotter,
drier climates or at higher elevations will require
more water due to evaporation of water through
the skin than those living in more humid conditions or at sea level. The quality and preparation of
food can also impact hydration needs, as canned
and some frozen foods (e.g., TV dinners) are high
in sodium, requiring increased water intake to
balance the increased intake of salt. However,
even accurate assessments of fluid intake may
not be sufficient, as knowledge does not equate
to adherence to such guidelines.
Systemic barriers may also serve as a complicating factor. Insufficient knowledge regarding
proper hydration in older adults may impede
proper management. Staff in residential homes
may incorrectly assume that more able residents
are independent and thus do not require reminders
to drink fluids throughout the day (Jimoh et al.
2015). A study that asked older adults to self-
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report their fluid intake during a 24-h period
showed that residents’ self-reported fluid intake
was more highly correlated with researcher’s
observations compared to staff records (Jimoh et
al. 2015). Even when properly trained in hydration management, senior staff do not have the
resources to monitor staff members after they
receive training, which can make it difficult to
assess if skills learned in training are implemented
in practice (Spilsbur and Meyer 2005). High staff
turnover, improperly recording patients’ unfinished drinks, and lack of educational training
could explain such discrepancy between staff
records and patients’ actual consumption of
water (Jimoh et al. 2015).
Need for Better Assessments
Despite limitations to hydration assessment,
research suggests that bioelectrical impedance
analysis (BIA, i.e., delivering a current through
electrodes to detect body fat mass) is a noninvasive measure to identify signs of dehydration in
older adults (Goldberg et al. 2014). Research indicates that saliva osmolality, which uses a saliva
sample to measure levels of electrolytes and water
in the body, is a promising method to detect early
dehydration. Saliva osmolality has been shown to
detect dehydration more accurately than other
diagnostic tests and should be tested in future
research (Lešnik et al. 2017).
Need for Effective Interventions
Indeed, research has indicated the need for sustainable treatments to manage hydration. For
example, Hsiao and Hing (2014) found that
older adults who were hospitalized for dehydration were more likely to receive subsequent hospitalizations. Such frequent hospitalizations
suggest that older adults may not see a need for
intervention to increase fluid intake if the problem
is not pressing (Feliciano 2005).
Preliminary studies also suggest that functionbased interventions that are tailored to individual
needs can be successful in managing dehydration
in an individual’s home but future work is necessary to determine the efficacy of such interventions (Feliciano et al. 2010).
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Future Directions of Research
Considering the limitations of current efforts to
manage dehydration in older adults, it is essential
that future research focus on developing interventions to sustain necessary hydration habits.
Research should have a dual focus: education
and management at the individual level and at
the institutional level. To address the lack of
home interventions for older adults, future
research could incorporate strategies such as
memory prompts or reminders to cue drinking or
meal time (Feliciano 2005). Such strategies could
utilize new technologies as simple environmental
interventions, such as insulated tumblers to keep
beverages cold (Feliciano et al. 2010) or the use of
fruit infused water bottles to improve flavor. Additionally, future research could address functional
barriers faced by older adults (e.g., severe arthritis, homebound, frail, limited transportation)
through the use of supportive devices (weighted
gloves for those with essential tremor) or delivery
services to provide and set up water beverage
stations within the home. Lastly, healthy beverages could be promoted by meal delivery services
(e.g., Meals on Wheels).
In institutional settings, altering environmental
factors such as using brightly colored cups and
serving beverages during social activities could
create a positive association with drinking
(Dunne et al. 2004; Miller 2015). Increasing the
color contrast of the cups may also increase visibility of liquids, signal the availability of social
interaction, and promote beverage consumption.
For example, researchers utilized a beverage cart
with brightly colored cups and pitchers and
reported that this increased the interest of longterm care residents, allowing staff to offer choice
of beverages, and increased beverage consumption (Robinson and Rosher 2002). They reported
that by increasing fluid by only 16 oz per day, they
found positive results including total body water
and decreases in negative events such as constipation and urinary tract infections.
Education and training in assited living and
other long-term care facilities is needed. Future
Dehydration in Older Adults
work could focus on developing programs for
nurses or caregivers in hospitals and residential
care settings to ensure older adults receive proper
hydration. For example, a recent study found that
medical interns who completed an educational
program about risk factors for hazards of hospitalization (HOH) for older adults (e.g., delirium,
dehydration, etc.) demonstrated increased knowledge and self-efficacy for planning prevention of
risk factors compared to medical interns who did
not complete the program (Wilkerson et al. 2014).
Providing more fluid with medications can
assist in increased fluid intake and help decrease
the dehydrating side effects of medication (Jimoh
et al. 2019). Research examining residents’ selfreported fluid intake indicated most beverages
were consumed during the morning and in
between meals, which suggests that offering
drinks routinely throughout the day may increase
older adults’ fluid intake (Jimoh et al. 2019).
Offering choice of healthy beverages throughout
the day could promote beverage consumption,
and research has indicated that this simple behavioral intervention was effective at increasing beverage consumption in long-term care (Simmons
et al. 2001; Spangler et al. 1984).
Lastly, future research could also focus on
creating experiential training programs, as programs that solely focus on education may not be
sufficient enough to produce lasting change in
staff members’ skills. Training programs incorporate experiential activities such as allowing staff
members to role-play, take quizzes about dehydration, and engage in group discussions (Nolan
et al. 2008). Interactive activities might help support staff empathize with residents and better
serve residents. For example, staff members in
an experiential training program found it useful
to taste thickened fluids as it helped to understand
residents’ experience and recognize the importance of appropriately preparing thickened fluids
(Greene et al. 2018). Furthermore, staff members
who listed their beverage preferences recognized
they assume residents’ preferred beverages and
that respecting individual preferences can help
increase fluid intake (Greene et al. 2018).
Dehydration in Older Adults
Summary
Dehydration is a serious medical concern and is
highly prevalent in older adults. Older adults are
susceptible to dehydration due to age-related processes associated with decreased physical and
sensory abilities. Thus, dehydration management
may be difficult as functional decline can impair
an older adult’s ability to access fluids. Although
dehydration is adequately treated in hospitals,
current interventions do not incorporate methods
to help community dwelling older individuals to
manage hydration after receiving treatment. In
residential facilities, efforts to prevent dehydration are inadequate, as staff members do not
receive sufficient training about dehydration in
older adults. Future research should focus on
developing feasible and sustainable interventions
for dehydration detection and management.
Cross-References
▶ Body Mass Index
▶ Healthy Diet
▶ Improving Nutrition in Old Age
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