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Prevalence, risk factors and strategies to prevent dehydration in older adults

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DOI: 10.5172/conu.673.31.1.44 · Source: PubMed

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Prevalence, risk factors

and strategies to prevent
dehydration in older adults
ABSTRACT The treatment of dehydration in older adults admitted from residential care to
an acute hospital setting may lead to haemodynamic stability.There is however
an increased risk for short or long term alterations in physiological, cognitive
and psychological status and ultimately, decreased quality of life. Such acute
Key Words care admissions could be decreased where preventative strategies tailored to
address individual risk factors are combined with more frequent assessment of
dehydration;
fluid-electrolyte the degree of hydration.The questionable reliability of assessment criteria in
balance; older adults increases the need to use multiple signs and symptoms in the
hospitalisation; identification and differentiation of early and late stages of dehydration.This
older adults; article reviews various risk factors, explores the reliability of clinical signs and
elderly; symptoms and reinforces the need to use multiple patient assessment cues if
residents;
nurses are to differentiate between, and accurately respond to, the various causes

CN
hypovolaemia;
assessment; of dehydration. Specific strategies to maintain hydration in older adults are also
nursing identified.
Received 3 August 2007 Accepted 15 September 2008

KAREN WOTTON KARINA CRANNITCH REBECCA MUNT

Senior Lecturer in Nursing Registered Nurse Associate Lecturer in Nursing
School of Nursing & Midwifery The Alfred ICU School of Nursing and Midwifery
Flinders University Prahran VIC, Australia Flinders University
Adelaide SA, Australia Adelaide SA, Australia

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Prevalence, risk factors and strategies to prevent dehydration in older adults
INTRODUCTION
M aintaining the delicate fluid and elec-
trolyte equilibrium of older adults (>65
years of age) is an integral part of nursing care.
Deficits in fluid volumes are common, manifest
rapidly and can have potentially fatal conse-
quences particularly for the older adult with
numerous comorbidities and dampened, labile
homeostatic mechanisms. Dehydration is the
result of a fluid imbalance therefore an inade-
quate circulating volume resulting from either
the consumption of too little fluid or due to a
loss of too much fluid (Metheny 2000; Mentes
2006) The degree of dehydration is correlated
with the percentage of Total Body Water (TBW)
lost and correlated with particular changes in
signs and symptoms to be classified as mild to
severe. In older adults 3% loss of TBW is con-
sidered significant and should be corrected as
the condition can rapidly deteriorate to severe
dehydration.
Older adults living in residential care facili-
ties are often admitted to hospital for manage-
ment of low to moderate levels of dehydration
(Thomas et al. 2003; Xiao et al. 2004). Such
admissions expose older adults to risks of acute
confusional syndromes, delirium, and nosoco-
mial infections (Barton et al. 2004). Important-
ly, dehydration is preventable and reversible if
TABLE 1: CALCULATING FLUID REQUIREMENTS
Author mL for first 10 kg
Skipper (1993) 100 mL/kg
Austin (1996) 100 mL/kg
TABLE 2: DIFFERENCES IN CALCULATED DAILY FLUID INTAKE USING THREE FORMULAS
Calculated daily fluid volumes
Weight 30 mL/kg/day Skippers’ formula
40 kg 1200 mL
50 kg 1500 mL
60 kg 1800 mL
70 kg 2100 mL
80 kg 2400 mL
CN
identified early. It is therefore, imperative that
nurses are proactive in the monitoring and clus-
tering of all available cues to exclude fluid and
electrolyte problems for all older persons con-
sidered at risk. The aim of this review is to
extrapolate published information relating to
the causes, prevention and consequences of
dehydration in older adults, as well as, the as-
sessment of hydration status.
FLUID REQUIREMENTS OLDER
ADULTS
An adequate fluid intake for older adults is cal-
culated at 30 mL/kg/day equating to between
1,500 to 2,000 mL (Eaton et al. 1999). This
generalised rule or two other more specific for-
mulas can be used to calculate fluid require-
ments in older adults (Table 1).
The difference between daily fluid require-
ments calculated using different formulas
(Table 2) is quite significant and could lead to
either underhydration or overhydration. The
difference for example, between using the for-
mula for 30 mL/kg/day and Austin’s (1996)
formula for a 60 kg individual is 700 mL/day.
The fluid requirements for older adults should
therefore be individually calculated and take
into account initial and ongoing assessment of
the degree of hydration and comorbidities. In
mL for next 10 kg mL for remaining kg
50 mL/kg 15 mL/kg
50 mL/kg 25 mL/kg
Austin’s formula
1800 mL 2000 mL
1950 mL 2250 mL
2100 mL 2500 mL
2250 mL 2750 mL
2400 mL 3000 mL
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CN Karen Wotton, Karina Crannitch and Rebecca Munt

addition, age, gender, obesity, renal and cardiac to possess statistical significance but above three
disease, need to be considered if fluid overload risk factors suggest a higher risk for dehydration.
is to be avoided. The following section provides a discussion
of the importance of the major risk factors list-
HYDRATION STATUS OF OLDER ed in Table 3.
ADULTS
Dehydration is associated with increased A. Individual variables
morbidity and mortality (Bennett et al. 2004;
Age
Chassagne et al. 2006).The prevalence of dehy-
dration in older adults is significant whether Older adults undergo a decrease in total body
they live in the community or in residential care water (TBW) percentage as they age which
facilities (Thomas et al. 2003; Xiao et al. 2004). increases susceptibility for dehydration (Lan-
Direct observation of fluid and dietary intake of caster et al. 2003; Bennett et al. 2004; Mentes
older adults in nursing homes have shown inade- 2006). Kidney function, urine concentration,
quate intake in 50–90% (Chidester & Spangler thirst sensation, aldosterone secretion, release
1997). In many instances older adults with in- of vasopressin, and renin activity are all signifi-
creased independence and access to palatable cantly lowered with age (Lancaster et al. 2003;
fluids are often incorrectly assumed to be more Lukey & Parsa 2003; Xiao et al. 2004). This
likely to maintain adequate fluid intake (Thomas decrease in the normal compensatory responses
et al. 2003; Xiao et al. 2004). The presence of to lower blood pressure or lower blood volume
dehydration increases the risk of renal failure, further increases the older adults risk for a
decubitus ulcers, constipation, urinary tract in- more rapid escalation of dehydration than in the
fections, medication toxicity, respiratory infec- younger population.
tions, acute confusion, decreased muscle strength Age, gender, height and weight influence the
and falls (Eaton et al. 1999; Mentes 2006). The percentage of TBW but these factors are rarely
haemoconcentration associated with dehydra- taken into account in the development of fluid
tion increases blood viscosity and increases maintenance plans or in the assessment of hyd-
the risk of deep vein thrombosis (Metheny ration status. In early senescence there is a sig-
2000). In addition, the associated tachycardia nificant and steady decrease in the percentage of
decreases time in diastole and coronary arterial TBW to a low of 50–52% (males) and 45–
filling time and increases the risk of myocardial 47% (females) of total body weight. Using the
ischaemia. information in Table 4 the TBW of a 30-year-old
female weighing 55 kg would be 27.5 L where-
RISK FACTORS FOR FLUID AND as a 70-year-old woman with the same weight
ELECTROLYTE DEFICITS IN OLDER would have a TBW of 24.75 L. Similarly, a 30-
ADULTS year-old male weighing 70 kg would have a
Risk factors for dehydration in older adults are TBW of 42 L whereas a 70-year-old male of the
multivariant and the more risk factors the same weight would have a TBW of 35 L. Adi-
greater the likelihood for dehydration. Nurses pose tissue is practically free of water thus the
are advised to use a systematic approach in proportion of water to body weight is less in
assessing risk factors in early prevention and obese individuals and in females, both who have
management of dehydration.Table 3 provides an a relatively larger amount of subcutaneous adi-
example of risk factors identified by the authors pose tissue compared to muscle mass. Gender dif-
from an analysis of available literature. At the ferences are significant in any estimation of fluid
present time no one risk factor has been shown loss or fluid required by individuals (Table 4).

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Prevalence, risk factors and strategies to prevent dehydration in older adults CN

TABLE 3: IDENTIFICATION OF RISK FACTORS FOR DEHYDRATION IN OLDER ADULTS

Risk factor Present Risk factor Present

A. Individual variables D. Increased insensible loss

Age > 70 years  Hyperglycaemia 

Gender – female  Infection 
Race – black  Increased body temperature 
High or low BMI  Increased environmental temperature 
Cultural – different culture and usual foods  Increased diaphoresis (perspiration) 
Increased respirations 
B. Relocation/transfer
E. Decreased access to, or request for, fluids
Recent hospitalization 
New admission to a residential Alterations in mental health status 
care facility/hospital  Decreased cognition 
C. Physiological status Dementia 
Inability to speak/understand English 
Malnutrition  Inability to verbalise thirst 
Fluid intake (including fluid gained
from diet) < 1.5 L/day  F. Decreasing fluid intake
Previous history of dehydration 
Swallowing disorders 
Diabetes mellitus 
Alteration in oral health status 
Alterations in mobility 
Decreased access to fluids 
Alterations in renal function 
Decreased olfactory sensation 
> 3 medical conditions 
Decreased taste sensation 
Vomiting/diarrhoea/ileostomy 
Decrease visual acuity 
Polypharmacy 
Diuretics 
Chronic dehydration 

Age substantially increases the risk of fluid
and electrolytes problems as illustrated by the
difference between the TBW of 30 L for a 60 kg
woman (without taking into account a dec-
reased TBW associated with older age) and a
TBW of 27 L if she was of the same weight but
over 75 years of age.The 3 L decrease in TBW is
quite significant when calculating fluid volume
requirements or in estimating the degree of
TABLE 4: FORMULA FOR CALCULATION OF BODY FLUIDS
dehydration.Table 5 shows the significance of a
loss of 1 kg (1000 mL) on TBW, ECF (extracel-
lular fluid) and plasma for four persons of dif-
ferent body weight.
Gender
Female gender was identified as an independent
risk factor for dehydration in older adults (Ben-
nett et al. 2004). The risk of insufficient fluid

Younger adult Adult > 70 years of age

TBW Female Lean body weight x 50% Lean body weight x 45%
TBW Male Lean body weight x 60% Lean body weight x 50%
ICF 2/3 x TBW 2/3 x TBW
ECF 1/3 x TBW 1/3 x TBW
Interstitial volume 0.75 x ECF 0.75 x ECF
Plasma volume 0.25 x ECF 0.25 x ECF

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CN Karen Wotton, Karina Crannitch and Rebecca Munt

TABLE 5: COMPARISON OF THE PERCENTAGE LOSS IN BODY FLUID VOLUMES WITH A 1L FLUID LOSS

Usual TBW 1 L = % loss ECF 1L=% Plasma 1 L = % loss

weight normal TBW normal ECF normal plasma volume

44.5 kg 20 L 5% 6.7 L 14.9% 1.7 L 59%

60 kg 27 L 3.7% 9L 11% 2.25 L 44%
66.5 kg 30 L 3.3% 10 L 10% 2.5 L 40%
78 kg 35 L 2.86% 11.68 L 8.6% 2.9 L 30%
(Wotton 2006.)

intake in older females was also associated with weight loss (Walker et al. 2007) and can ulti-
poor drinking habits such as drinking small mately result in malnutrition and dehydration.
amounts due to fear of incontinence (Mentes
2006). C. Physiological status
Malnutrition
Race: Black
Lancaster et al. (2003) found African American The strong association between inadequate
people were 1.5–2 times more likely to be diag- nutritional intake and dehydration exists
nosed with dehydration in comparison to white because up to 70% of the daily fluid require-
people in the elderly population. ment can be obtained from diet.The finding of
malnutrition in 40% to 70% of older adults on
High or low BMI hospital discharge (Elia & Stratton 2000) and
those already residing in residential care facili-
Older adults who are highly obese have a lower
ties (Clay 2001;Wouters-Wesseling et al. 2002;
TBW due to increased body fat and therefore
Lauque et al. 2004) confirms the importance of
lower fluid requirements.
assessing for dehydration when older adults
return to or are admitted to a residential care
Cultural facility or commence to decrease dietary intake.
The cultural and psychosocial environmental Table 6 contains examples of the approximate
also has a direct relationship to an individual’s amount of fluid content for a range of food.
dietary and fluid intake (Lancaster et al. 2003; Older adults with dysphagia who required
Xiao et al. 2004). A change in the types of food thickened fluids were found to be at higher risk
and fluids available, daily routines and/or in the for dehydration because of the time required to
physical dining environment will impact on the drink the prescribed volume and the lack of
quantity of both fluid and dietary intake. supervision by nurses (Whelan 2001).

B. Relocation/transfer Fluid intake

New admission to a residential care facility/
hospital can result in relocation stress. Reloca-
tion stress syndrome (RSS) is the physiological,
psychological and social disturbances as a result
of transfer from one environment (home) to
another (residential care facility or hospital)
(Walker et al. 2007). Signs and symptoms as-
sociated with RSS including anxiety, mood
swings, confusion, anorexia, social isolation and
The adequacy of fluid intake for older adults is
also problematic. As much as seventy percent of
daily fluids are derived from food older adults
who regularly fail to finish their meals are risk
of inadequate fluid intake (Shipman & Hooten
2007). Older adults with polpharmacy who
were offered fluids with medications were more
likely to have a higher fluid intake than older
adults on fewer or no medications (Eaton et al.

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Prevalence, risk factors and strategies to prevent dehydration in older adults CN

TABLE 6: WATER CONTENT OF FOODS

Food Fluid content Food Fluid content

Broth/soup 6 oz 180 mL Porridge 1 cup 160 mL

2 tbs gravy/sauce 40 mL 1 ice-block on a stick 90 mL
Rice/pasta 1 cup 100 mL Yoghurt 200 g 160 mL
2 oz cottage cheese 40 mL Jelly/custard ½ cup 100 mL
Raw tomato 30 mL Apple sauce ½ cup 90 mL
Cooked beans 45 mL Pudding ½ cup 100 mL
Cooked carrot ½ cup 45 mL Melon ½ cup 100 mL
Broccoli ½ cup 50 mL Apple 80 mL
1 orange 90 mL

1999). Mentes (2006) found that older adults (n dration (Hodgkinson et al. 2003). Lack of sup-
= 35) could be classified as ‘can drink’ but port from family or friends to assist older adults
unaware of adequate fluid intake or forget with alterations in mobility at meal times has
to drink, ‘can’t drink’ who were physically also been shown to negatively impact on food
dependent or had dysphagia or ‘won’t drink’ consumption (Shipman & Hooten 2007).
which included those older adults who reduced
their intake due to fear of incontinence or those Alterations in renal function
who tended to sip fluids.Thirty one percent of Known alterations of kidney function in older
older adults in Mentes (2006) study experi- adults over the age of 65 which place them at
enced a dehydration episode in the six-month risk for fluid and electrolyte imbalances include
study. a decrease in glomerular filtration rate (GFR),
a decreased ability to concentrate urine and
Diabetes mellitus reduced limits for the excretion of water and
Hyperglycaemia increases osmotic diuresis due electrolytes such as sodium, potassium and acid
to excessive circulation of glucose drawing (Luckey & Parsa 2003).
water out of circulation resulting in water loss
from both the intravascular compartment and Loss of fluids
intra and extra cellular sites (Page & Hall 1999). Any condition, which causes fluid loss, places
Hyperglycaemia and dehydration will lead to older adults at risk for dehydration. This inc-
Hyperosmolar non ketotic syndrome (HONK) ludes laxative use/abuse, vomiting, diarrhoea,
in older adults diagnosed with Type 2 Diabetes loss through ileostomy, increased insensible loss
Mellitus and Diabetes ketoacidosis in those diag- associated with hyperglycaemia and increased
nosed with Type I Diabetes (Page & Hall 1999). environmental temperature. Lactulose, a hyper-
osmolar laxative, acts by drawing water into the
Alterations in mobility intestines and therefore increases the water con-
As dehydration is correlated with decreased tent of the faeces (Ratnaike et al. 2000). Lactu-
access to fluids in older adults (Simmons et al. lose should only therefore be used for older
2001) individuals with alteration in mobility are adults who are well hydrated. The finding that
at higher risk. The use of chemical or physical increased temperature and increased insensible
restrains, being wheelchair or bed bound has a loss associated with infections was only partly
great propensity to decrease access to fluids responsible for the degree dehydration suggests
(Davidhizar et al. 2004). Capable, semi-inde- that other aetiologies are also responsible for
pendent individuals were also at risk for dehy- dehydration in this situation (Bennett et al. 2004).

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CN Karen Wotton, Karina Crannitch and Rebecca Munt
Poly-pharmacology and
diuretic use
The use of medications (for example, diuretics,
vasodilators, β1 Blockers, aldosterone inhibi-
tors, ACE inhibitors and Angiotensin II in-
hibitors) directly effecting fluid and electrolyte
balance increases the risk of dehydration. Med-
ication can also cause dehydration by impairing
the kidneys concentrating ability (Lithium, potas-
sium-losing diuretics) or simulating the synd-
rome of inappropriate anti-diuretic hormone
secretion (Tricyclic antidepressants, selective
serotonin reuptake inhibitors, phenothiazines,
antineoplastic drugs, chlorpropamide, carba-
mazepine and narcotics (Miller 1997). Medica-
tions can either increase loss of fluid and
electrolytes (for example, diuretics), dampen
the compensatory mechanisms, which assists in
maintaining circulating volume to vital organs in
the early stages of dehydration (for example, β1
blockers or ACE inhibitors), decrease mobility
or cognitive functioning (for example, MOA
inhibitors, and barbiturates) or cause dryness of
oral mucosa even in the absence of dehydration
(for example, diuretics and anticholinergics).
One case-control study found that diuretics
might be significantly associated with the diag-
nosis of dehydration (Lancaster et al. 2003)
whereas two other studies found a similar pro-
portion of diuretic use between subjects with
dehydration and without dehydration (Bennett
et al. 2004; Chassagne et al. 2006). Therefore,
although diuretics can increase the risk for
dehydration, the combination of risk factors for
example polypharmacy, older age and decreased
mobility are more significant than a single risk
factor.
Chronic dehydration
Many older adults are highly susceptible to a
rapid transition from a seemingly hydrated state
to acute dehydration because of chronic under-
hydration. Frail older adults with possible
chronic dehydration are at extreme risk of acute
dehydration with even small environmental
50 CN Volume 31, Issue 1, December 2008
physiological stressors (for example, infection
or increased environmental temperature) (Mentes
et al. 2000). An estimated mean daily fluid
intake of less than 1000–1500 mL/day for over
33% of older adults in residential care facilities
(Chidester & Spangler 1997; Mentes et al. 2006)
suggests a chronic state of dehydration. The
chronicity of dehydration in older adults admit-
ted from residential care settings to emergency
departments was made using medical records
and criteria from the International Classification
of Diseases – 9 diagnoses of dehydration (War-
ren et al. 1994), Bun:Creatinine ratio > 20:1
(Lindeman et al. 2000; Simmons et al. 2001),
elevated serum sodium or, a combination of ele-
vated Bun:creatinine, elevated serum sodium
(> 145 mEq/L) and a retrospective analysis of
signs and symptoms of dehydration in medical
records (Bennett et al. 2004).
D. Increased insensible loss
Many physiological, environmental and pharma-
cological factors cause increased diaphoresis
(perspiration) and place the patient at risk for
dehydration. Hyperglycaemia, infection, hyper-
pyrexia and tachypnoea can markedly increase
insensible loss both alone or even more so
when two or more of these occur concurrently.
Medications like for example, tricyclic antide-
pressants promote diaphoresis. Increased envir-
onmental temperature whether because of
natural heat or air conditioning also increases
diaphoresis and insensible loss.
E. Decreased access to, or request
for, fluids
Decreased cognition
Alterations in cognitive functioning are associ-
ated with risks for dehydration. A strong link
was found between dehydration and hyperna-
tremia, and dementia, altered consciousness
and/or poor cognitive skills (Lancaster et al.
2003; Bennett et al. 2004; Chassagne et al. 2006).
Dehydration also negatively affects short-term
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Prevalence, risk factors and strategies to prevent dehydration in older adults CN

memory, visuo-motor skills and the ability to STRATEGIES TO MAINTAIN FOOD
think and to reason (Cian et al.2000) and often AND FLUID INTAKE IN OLDER
signals the presence of dehydration. ADULTS
Prevention of dehydration in older adults is bet-
F. Decreasing fluid intake ter than cure and ideally the responsibility
Swallowing disorders, decreased olfactory sen- should be shared by medical, nursing and
sation and decreased taste has been associated dietary staff (Mentes et al. 2006). Educational
with dehydration in older adults (Asai 2004). programs and information on risk factor identi-
Oral problems for example, ill fitting dentures, fication, monitoring, and early management
missing teeth, oral mucositis (stomatitis) and strategies needs to be more readily available to
thrush can also interfere with fluid and nutri- nurses working with older adults.
tional intake (Clay 2001). Age-related changes Nutrition is often perceived as a component
in taste (taste buds decrease by 65% by the of a hotel service therefore it is not surprising
age of 74–85 years), smell and vision increase that responsibility for monitoring fluid and
the risk for dehydration. Difficulty articulating nutritional intake in residential care settings is
needs, inability to verbalise thirst, inability to usually informally delegated to carers rather
speak or understand English and decreased than registered nurses (Clay 2001). Integral to
mobility are also prevalent risk factors (Bennett strategies to maintain fluid and electrolyte bal-
et al. 2004). ance in older adults is responsibility for fluid
monitoring. Fluid and diet monitors should be
CLINICAL INDICATORS OF appointed on each shift.This should be accom-
HYPOVOLAEMIA panied by the calculation of a fluid goal for all
The complications of dehydration increase older adults using one of the formulas and
sequentially if not treated early. It is essential knowledge of their medical diagnoses.
that a full nursing history is elicited and regular- Early identification of risk factors and dehy-
ly updated for all older people in residential dration by nurses is an essential strategy, which
care settings which can be used in the interpre- requires knowledge of the older adult. Knowing
tation of a more focused assessment for dehy- the older adult means understanding their
dration. If treatment is prompt, progression is unique situation and usual physical and psychoso-
arrested but if fluid loss continues or fluid cial responses to changes in their internal and
intake does not increase, compensatory mecha- external environment (Radwin 1994). Nurses
nisms begin to fail resulting in decreased tissue need time – time to get to know older adults in
perfusion. Nurses require a sound knowledge of their care. Knowing the person is difficult to
clinical criteria to adequately assess for dehydra- achieve but should already be a feature of nursing
tion (Table 7). Ultimately, as the validity and practice in residential care settings because of the
reliability of these criteria are questionable a close and ongoing relationship between nurses
multivariate rather than a univariate approach and older adults.
to assessment is required (Wotton & Redden The adequacy of nursing assessment and doc-
2002). In addition, it is essential that nurses, in umentation of dehydration is questionable (Ben-
assessing clinical status, interpret the pattern nett et al. 2004). Documentation developed in
and trend of all clinical data. Table 8 has been conjunction with the resident and/or their rela-
developed by the authors to highlight criteria tives of dietary and fluid preferences, preferred
which can be used in the identification of dehy- meal times, usual dining environment and spe-
dration and how to interpret this information cial dietary considerations (e.g., food allergies,
when assessing dehydration in older adults. cultural and religious needs, swallowing diffi-

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CN Karen Wotton, Karina Crannitch and Rebecca Munt

TABLE 7: CRITERIA FOR ASSESSING DEHYDRATION ( PAGE 1 OF 2, CONTINUES ...)

Assessment Comments
Postural A decrease in BP caused by a position change (lying to standing or lying to sitting), is one of
hypotension the first indicators of hypovolaemia. If BP decreases by 10% to 20% the possibility of volume
depletion is confirmed (Chassagne et al. 2006). Orthostatic blood pressure is present in
20–30% of community dwelling older adults, even in the absence of dehydration and is related
to venous incompetence or the effects of antihypertensive therapy (Thomas et al. 2003).
Blood Hypotension is a classic late sign of fluid depletion as compensatory mechanisms initially
pressure intervene to maintain BP within normal limits (Metheny 2000) and response to fluid loss may be
blunted by treatment for hypertension/cardiac disease (Mikhail 1999). A volume loss of less
than 500 mL may be clinically significant in older adults but cause minimal decrease in systolic
BP (Mikhail 1999).
Pulse Pulse pressure: difference between systolic and diastolic pressure is usually about 40 mmHg.
pressure (PP) PP is influenced by stroke volume, compliance of arteries and character of ejection during
diastole with decreasing PP an earlier sign of hypovolaemia than decreasing BP (Mikhail 1999).
Pulse Evaluate the rate, volume, regularity, and ease of obliteration of pulse. A rapid, weak, thready
pulse occurs in hypovolaemia. A systolic BP needs to be above 80 mmHg to elicit a radial
pulse, above 70 mmHg for a femoral pulse and at least 60 mmHg to feel a carotid pulse. Pulse
rate is a sensitive but non-specific indicator of dehydration. Older adults may not exhibit
tachycardia if prescribed cardiac medications such as beta-blockers or calcium channel
blockers. A postural pulse increase of over 30 beats per minute (or increase of 10–20%) is
indicative of hypovolaemia (Thomas et al. 2003).
MAP MAP is calculated by: (a) the diastolic pressure plus one-third of the pulse pressure; or (b)
diastolic pressure x 2 + systolic pressure ÷ 3. The cerebral and coronary circulations are
protected with normal blood flow unless the MAP falls below 50–65 mmHg.
Respiration Respiratory rate may not be a valid or reliable indicator in itself. Air hunger is a sign of shock as
the body attempts to compensate for tissue hypoxia. Breathing rates below 10/minute are a
late sign of shock and signal failure of compensatory mechanisms.
Urinary Urine output is a sensitive, although late, indicator of decreased fluid volume status Urine
output volume representing adequate renal perfusion is estimated at 0.4 mL/kg/hr female and
0.5 mL/kg/hr male (Metheny 2000).
Urine specific SG normally 1.010–10.25 mmol/L. Urine SG increase significantly (> 1.025–1.030) above 3–5%
gravity (SG) dehydration.
Urine colour The colour of urine is usually immediately responsive to small changes in hydration status
(Mentes et al. 2006). The urine colour chart developed by Armstrong et al. (1998) contains
8 colours ranging from pale straw to greenish brown.

culties, special utensils) should be regularly re-
evaluated and modified (Clay 2001). If the resi-
dent is eating normally, fluid intake should
equate to approximately 75% of the required
daily fluid requirement (Mentes 2000). For
older adults at risk for dehydration the written
plan may include offering fluids every 1 to 2
hours (Ferry 2005). Naturally, calculation of the
required hourly volume depends on dietary
intake. If no dietary intake the hourly required
oral intake (taking into account only waking
hours) would be approximately 100 mL.
The introduction of subcutaneous fluids (hypo-
dermoclysis) can prevent hospitalisation where
the older adult has signs and symptoms of mild
to moderate dehydration and is unable to con-
sume sufficient oral fluids to return to a normal
hydration status (Remington & Hultman 2007).
The use of subcutaneous infusions up to 84 mL
per hour are appropriate in residential care
settings (Hussain & Warshaw 1996;Worobec &
Brown 1997; Barton et al. 2004) as they can be
initiated by registered nurses, are simple to
commence and have a low incidence of prob-
lems (Noble-Adams 1995; Barton et al. 2004)
and have been found to decrease the need for
hospitalization (Remington & Hultman 2007).
The recommendations from research has not

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Prevalence, risk factors and strategies to prevent dehydration in older adults CN

TABLE 7: CRITERIA FOR ASSESSING DEHYDRATION (... CONTINUED , PAGE 2 OF 2)
Assessment Comments
Dry mouth May result from mouth breathing or administration of anti-emetics or anti-cholinergic
and lips medications.
Dry tongue A dry tongue without furrows is a less sensitive indicator of dehydration (Thomas et
al. 2003).
Thirst Degree of thirst is unrelated to dehydration severity and an unreliable indicator of
dehydration as thirst sensation is absent in two-thirds of older adults (Gross et al. 1992).
Muscle A decrease in muscle strength, muscle cramps and muscle fatigue can be an indicator of
strength dehydration due to a decrease in muscle intracellular volume (Ferry 2005).
Tissue Continuing pallor with cold, clammy skin signals peripheral vascular constriction.
integrity Cyanosis in the lips and nail beds may only mean that the patient is cold (Mikhail 1999).
Skin turgor Unreliable in older adults due to the decrease in collagen and elastin in the skin.
Abnormal forehead, subclavian or thigh skin turgor is however significantly associated
with dehydration in older adults (Chassagne et al. 2006).
Capillary Increased capillary refill time indicates peripheral vasoconstriction and decreased blood
refill time supply. Normally, the skin regains its former colour within 3 seconds with an increase above
4 seconds indicative of a loss of over 120 mL/kg (Metheny 2000).
Hand and Decreased hand and foot vein filling > 3–5 seconds precedes hypotension in an early stage
foot vein of dehydration.
filling
Axillary Decreased axillary moisture possesses poor sensitivity and a negative predictive value in
moisture detecting dehydration (Chassagne et al. 2006) but signals the need for further assessment
for dehydration (Eaton et al. 1999).
Sunken eyes A poor indicator in older adults due to the decrease in periorbital fat (Eaton et al. 1999;
Chassagne et al. 2006).
Neurologic Decreased neurologic status is a late finding of cerebral hypofusion (Mikhail 1999). Also
status unreliable because of pain relief, psychotropic medications and pre-existing dementia.
Input and Fluid balance is where total intake equals total output. For fluid balance to exist there
output – FBC should be a positive balance of around 300–500 mL/24 hours to take into account
insensible losses.
Body weight Any rapid change in weight is directly related to a change in fluid state. The degree and
severity of dehydration is calculated using percentage weight loss with mild dehydration
> 2%, moderate dehydration > 5% and severe dehydration > 8% in older adults.

however been introduced into practice.What is
required is the further exploration of the use of
hypodermoclysis in residential care settings and
the development of a protocol for when to initi-
ate hypodermoclysis, type of suitable fluids, the
amount of hourly fluid required, combined with
education for registered nurses.
Maintaining the balance of fluid and elec-
trolytes is essential in the prevention of dehy-
dration. The offering of mainly water, tea and
coffee to the older adults in residential care set-
tings should be denounced.Water intoxication
can occur when fluid consists mainly of water,
dietary intake is poor and in the presence of an
alteration in renal function. Fluids should
include water, fruit and vegetable juices, milk,
oral rehydration solution (ORS), low sodium
soups and decaffeinated beverages like herbal
tea. Although caffeine is contradicted in older
adults who are unwell it does not significantly
affect the hydration level of healthy adults
(Carey 2000). Decreased taste and smell should
see the inclusion of a light seasoning with herbs,
spices, lemon juice and mustard as well as the
thoughtful and colourful presentation of food
(Clay 2001).
Offering beverages outside of meal times,
and at a temperature which the individual pref-

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CN Karen Wotton, Karina Crannitch and Rebecca Munt

ers, increases fluid intake. One litre of waterequilibrium of older adults is an integral part of
nursing care of the elderly.The management of
left in a plastic jug by the bedside for 24 hours
becomes warm, impregnated with the taste of fluid and electrolyte balance requires a complex
mixture of skills including knowledge, expertise
plastic, unpalatable and this practice should be
discontinued. Instead the jug should be of a and an understanding of the underlying physio-
smaller volume and periodically emptied and logical principles of fluid balance in the body.
replenished. Above all, nurses require an ability to closely
Of equal importance is the dining environ- observe the subtle responses of older adults to
ment.The older adults’ environment should be fluid depletion, comprehensively assess, dis-
free of extraneous visual and olfactory sensa- criminate and effectively intervene, as every
tions.The environment should also be congruent person responds uniquely to such fluid imbal-
ances. This necessitates an understanding of
with their preferred environment whether it is at
both the normal and the timing of physiological
a dining room table or in front of the television.
Several authors recommend the use of happy response of the body to decreases in fluid vol-
hours (Mentes et al. 2000; Ferry 2005) where ume, and the ability to interpret patterns and
older adults can socialise. Happy hours could trends of all clinical indicators to identify early
include the juicing and consumption of fresh signs and symptoms.
fruit and vegetable juice and milkshakes made to Nursing assessments of dehydration in older
adults should include a full nursing history and
each resident’s specification. The social setting
and interaction between older adults has been physical assessment and an analysis and inter-
shown to increase levels of hydration, particu-pretation of clinical data. Nurses and caregivers
larly for those with dementia (Simmons et al. should encourage sufficient fluid and food in-
2001).Table 8 includes other prevention strate-take in older adults. Older adults may benefit
from education on adequate fluid intake, visual
gies for dehydration identified by Wakefield et al.
(2002), Ferry (2005) and Mentes (2006). reminders to drink, an increase in fluids of-
fered between meals, special drinking appara-
CONCLUSION tus or swallowing exercises. Dehydration is a
Maintaining the delicate fluid and electrolyte preventable condition; however inadequate fluid

TABLE 8: STRATEGIES TO PREVENT DEHYDRATION

Document Strategies to increase fluid consumption

• Older adult’s hydration and eating habits
• Usual weight, usual vital signs
• Older adult’s fluid preference and preferred
temperature of beverage
• Evaluation of medications for possible dehydrating
effects
Educate
• Older adults on the importance of hydration and
encourage drinking even when not thirsty
• Nurses and relatives on the importance of fluid and
foods to hydration and early recognition of any
decrease in resident’s usual patterns
• Nurses on the appropriate initiation of either oral rehyd-
ration solutions or subcutaneous rehydration and formu-
las for calculation of individualised daily fluid intake.
• Identify anorexia
• Replenish and refresh fluid supplies
regularly
• Balance caffeinated and alcoholic drinks
with other fluids
• Offer fluids regularly and encourage their
consumption – if necessary 1 to 2 hourly
• Use beverage carts to encourage fluid con-
sumption throughout the day not just at
meal times
• Offer ice-blocks and fluid rich foods
• Ensure access to drinks, positioning of older
adults, use of drinking straws, feeder cups
• Use of visual reminders to drink e.g. posters
• Check environment for obstacles.

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Prevalence, risk factors and strategies to prevent dehydration in older adults CN

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