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- 3 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). 4 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 References Begg DP (2017) Disturbances of thirst and fluid balance associated with aging. Physiol Behav 178:28–34 Belsky J (1999) The psychology of aging: theory, research, and interventions, 3rd edn. Brooks/Cole Publishing Co., Pacific Grove Blair KA (1990) Aging: physiological aspects and clinical implications. 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