Tips to Quench Thirst: Elderly Dehydration Prevention

With spring arriving and the summer months quickly approaching, dehydration prevention is vital to ensure the safety of our residents.  Water is a vital component in the human body. Approximately 60% of the total weight of the body is water, and every system depends on it to function properly.  Water is necessary for;
  • carrying nutrients to body cells
  • oxygen transportation
  • constipation prevention
  • body temperature regulation removal/flushing waste products from kidneys and liver organ/tissue protection
  • joint lubrication
  • maintenance of proper blood volume

Without sufficient blood the heart is unable to pump efficiently resulting in a decrease in the amount of blood to the brain, liver, and kidneys. Eventually this will result in multiple organ failure and ultimately death. Without water the human body will cease to exist!
Dehydration is often due partly to inadequate water intake, but can happen for many other reasons as well, including as a side effect of prescribed medication like diuretics, diarrhea, emesis, excessive sweating, loss of blood and diseases such as diabetes. With the summer months quickly approaching, the heat and humidity also contribute to dehydration. Aging itself makes people less aware of thirst and also gradually lowers the body’s ability to regulate its fluid balance.  As we age we lose water due to the loss of muscle mass and a corresponding increase in fat cells.  In addition, the kidneys’ ability to remove toxins from the blood progressively declines as they are not as efficient in concentrating urine in less water.
Signs and Symptoms of Dehydration:
  • Confusion
  • Poor skin turgor (elasticity)
  • Dry oral mucosa/dry furrowed tongue
  • Decreased pulse
  • Increased respirations
  • Concentrated urine
  • Weight loss

Confusion may be an early sign of dehydration. Staff  working regularly with a resident may be best able to detect subtle changes in mental status that are present when dehydration develops. Dehydration should be one of the first problems suspected when a resident has a sudden change in mental status.  Poor skin turgor accompanies dehydration, but this can be a difficult sign to assess because elderly residents have an age-related reduction in skin turgor under normal circumstances. If skin turgor is to be used in assessing for dehydration, the best areas to test are the skin over the sternum and forehead because these areas maintain better skin turgor than other areas. Generally, skin will feel warm and moist with dehydration. An inspection of the oral cavity can yield useful insight into a resident's hydration status. A dry oral mucosa and dry furrowed tongue are good indicators of dehydration. Staff should be cautioned that residents who are taking certain medications (such as anticholinergic drugs) may have dry oral mucosas in the absence of dehydration. Due to decreased blood volume, a measure of blood pressure will reflect lower results and the pulse/heart rate, and respirations will be elevated trying to compensate for the decreased volume.  A review of bowel elimination patterns can assist in assessing dehydration. Recent diarrhea can offer an explanation for a dehydrated state, while constipation is a common occurrence when dehydration exists. Likewise, bladder elimination patterns can provide useful insights: excess voiding can contribute to dehydration while scant output can indicate insufficient fluid intake. Concentrated urine which has a dark appearance and strong odor is a common sign. Because such a large percentage of the body is comprised of fluid, weight loss is often present.
From a regulatory outlook, F 327: §483.25(j) Hydration states that the facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. The intent is to assure that the resident receives sufficient fluids based on individual need to prevent dehydration.  Dehydration is defined as, “output of fluids far exceeds fluid intake”. “Sufficient fluid” means the amount of fluid needed to prevent dehydration and maintain health. The amount needed is specific for each resident, and fluctuates as the resident’s condition fluctuates (e.g., increase fluids if resident has fever or diarrhea).  The key word here is “Assessment”, observing to ensure that our residents are safe, which should be done using an interdisciplinary approach. 
If any of the above symptoms are observed, further assessment of the resident for dehydration accompanied by corrective interventions should be in place as soon as possible. The best defense against dehydration is prevention.   Proactive tips to “Quench thirst” and prevent dehydration include;
  • Routinely monitor residents for signs of dehydration. Observe the residents' consumption of fluids to determine if they have reduced the amount of liquids they usually drink. Pertinent observations should be recorded in the nursing notes.
  • Keep a list of residents at high risk of dehydration in the nurses' station and other strategic locations to remind others to monitor residents' fluid intake. Consider placing a symbol, such as a drop of water, near the beds of those residents at risk of dehydration as a sign for staff members to encourage fluid intake.
  • Establish hydration protocols to be instituted immediately when acute symptoms or illness threaten fluid and electrolyte homeostasis.
  • Offer at least a full glass of fluid (4-8 ounces) with medications.
  • Establish hydration protocols to be implemented immediately when acute symptoms or illness threaten fluid and electrolyte balance.
  • Offer smaller amounts of fluids to residents more frequently. For example, nursing assistants can offer small amounts of fluids every time they interact with residents during delivery of care; i.e. after a transfer, getting dressed, after therapy, etc…
  • Observe/assess residents' preferences for type and temperature of fluids, and individualize the hydration plan to encourage compliance.
  • Involve your consultant pharmacist to review residents' medications to assess possible impact of fluid and electrolyte levels.
  • Provide fresh water pitchers at residents' bedside and assure that residents are able to easily reach pitchers and glasses. Supply straws and special drinking glasses to assist residents as necessary. If there is a problem with swallowing, involve the team, and request a speech therapy consult for evaluation..
  • Staff should offer a variety of fluids at a variety of times and inform residents the purpose of this procedure. For example, the dietary staff could add a glass of water to each meal. Activities such as discussion or music groups should include the offering of beverages.
  • Arrange for residents to eat meals and have snacks with other residents. Residents typically consume more food and fluids in a social setting.
  • Educate residents, families, and staff about the importance of hydration.
  • Even involve state surveyors during their visit requesting that they offer something to drink to residents as they interview residents, as part of the overall facility efforts to prevent dehydration.
  • Educate staff on using a positive approach when administering fluids.  Avoid asking, “Do you want something to drink”, and replace that with, “Here is some cool, refreshing, water for you”. With aging the resident may not feel thirsty, and realize the importance of fluid intake.
Dehydration in our elderly residents is a common and dangerous problem requiring the involvement of the entire interdisciplinary team. Every opportunity to encourage residents to drink should be used, not only by nursing staff, but dietary, activities, social services, volunteers, family members, and members of your pharmacy team. By taking a proactive approach to preventing dehydration, staff members can make great progress in reducing unnecessary hospitalizations and maximizing resident health and well-being. So be proactive, and let’s “Quench the Thirst”!

Author: Erin McClure, BSN, RN, WCC,
Nurse Consultant, Institutional Care Pharmacy, Inc.
Contact email: emcclure@Icppharm.com
Works Cited:
Cramer, Margaret. "Preventing Dehydration in the Elderly." 7 February 2007. Nursing 211. April 2013. <http://nurs211f07researchfinal.blogspot.com/2007/12/preventing-dehydration-in-elderly.html>.
"The importance of water." 2013. Illinois Council of Long Term Care. April 2013. http://www.nursinghome.org/fam/fam_018.html.

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