PREVENTING DEHYDRATION IN THE ELDERLY

Margaret Cramer
Water is the most essential component in the human body. Without water the human body is unable to function and will die. Many infections in the elderly have been linked to dehydration and if not diagnosed early enough the mortality rate can be as high as 50% (Ferry, 2005, p. 1). The nurse may be the only factor that will determine life or death in an elderly patient and that is why it is so important to be able to detect dehydration early as well as teach prevention.
Water is an essential component in the everyday functioning of the human body. Approximately 60% of the total body weight is water (Water, 2007, p. 1). Every system in the body depends on water to function properly. Water is necessary for:
Carrying vital nutrients to the body cells.
Transportation of oxygen to the cells.
Is a major factor in the prevention of constipation.
Helps to regulate the body temperature.
Is vital to the liver and kidneys to flush out waste products.
Provides protection for the bodies major organs and tissues.
A vital component in the lubrication of joints.
Is a major part of the tissues in the eyes, nose, and mouth.
When the body becomes dehydrated, and the fluids are not replaced, there is a decrease in the total blood volume. The sympathetic nervous system will then cause vasoconstriction resulting in an increase in the heart rate to compensate for the decreased tissue perfusion (Black, Hawks, 2005, p. 208). 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!
What causes the body to become dehydrated? There can be many contributing factors that will cause the loss of fluid such as:
Exercising will cause increased sweating.
If the weather is hot or humid, heated indoor air, or higher altitudes.
Illnesses that cause nausea, vomiting, diarrhea, and fevers.
Medications such as diuretics, laxatives, or even sedatives.
Diseases such as diabetes, draining wounds, or even depression which causes a decrease in appetite.
The elderly are at a greater risk of becoming dehydrated because of numerous factors. As the body ages there are changes in body functions that are directly related to the aging process. According to Levi the major changes are a decrease of 20% in the metabolic rate between the ages of 20 and 90 years of age, a reduction of lean body mass (muscle) accompanied by a decrease in the amount of physical activity, thereby resulting in an increase in body fat (2005, p. 6). Fat is almost completely free of water; whereby muscle can contain 73% water, so with the increase in fat, and the loss of muscle, this also will contribute to the incidence of dehydration in the elderly (Ferry,2005, p. 3). Other factors that increase the incidence of dehydration in the elderly is the aging process that will cause a decrease in the sensation of thirst, the gag reflex weakens, and some elderly will develop swallowing disorders which will greatly impact their intake of fluid. Some may even decrease their intake of fluid because of the fear of incontinence. Because dehydration can occur at a faster rate in the elderly it is vital to know the signs and symptoms.
In order to be able to detect dehydration early it is important to know the causes of dehydration and what to look for when assessing an elderly patient. The following signs and symptoms should be looked for when doing an assessment:
Skin turgor needs to be assessed; but remember because of decreased elasticity with aging you need to check for turgor either on the forehead or the sternum.
The patient may appear disoriented, become easily irritated, or become dizzy or faint with position changes.
Muscle tone or any muscle weakness needs to be assessed.
Postural vital signs need to be taken to evaluate any increase in heart rate or if hypotension is present. According to Black and Hawkins (2005) hypotension is a classic sign of a decrease in fluid volume and is defined as:
"A decrease in systolic blood pressure of more than 25 mm Hg.
A decrease in diastolic pressure of more than 20 mm Hg.
A pulse increase of 30 beats/min or more when the patient stands (p.208) ."
Patient’s may have trouble with constipation, a decrease in urine output with urine that is dark or has a strong odor to it.
Weight should be assessed. A loss of two or more pounds in a few days can amount to a body loss of a liter of fluid.
Jugular veins may appear flat when patient is lying down and capillary refill will be less than 5 seconds.
A decrease in fluid will cause the body temperature to rise.
Labs such as urine specific gravity, blood urea, nitrogen, electrolytes, or hemoglobin values that are abnormal are also useful tools in the dehydration assessment.
The patients current medications also need to be charted. Diuretics will increase the incidence of fluid loss and if accompanied by an illness, dehydration may occur at an even more rapid rate.
What can be done to decrease the incidence of dehydration in the elderly? First of all it is important that the elderly, their caregivers, their nurses, as well as their health care providers make it a top priority to all be aware of the signs, symptoms, as well as the health risks of dehydration. Prevention needs to become a top priority and these nursing interventions should be implemented as well:
Including foods in the diet that have a high water content. Such as fresh fruits, vegetables, watermelon ( which is almost all water), yogurt, or even jello.
Encouragement to increase fluid intake when ill.
Teaching that when exercising fluid consumption needs to be increased.
Teaching that if the temperature increases either indoors or outdoors that the need for increased fluid intake will increase as well.
Patient’s should be educated that even if they don’t feel thirsty they still need to drink.
Caregivers need to make beverages as accessible as possible to those that have decreased mobility, dyspagia problems and offer a wide variety of choices.
Since dehydration has been identified as the most common fluid and electrolyte imbalance in the United States, prevention should be the first and foremost step, followed by the ability to recognize the early signs and symptoms of dehydration (Black, Hawks, 2005, p. 205). With everyone working together the incidence of dehydration can be greatly diminished as well as the risk to an elderly person’s health.
Intervention 1 Patient’s need to be educated to drink even when they don’t feel thirsty.
Disadvatange: Meg Sibal M.D. from the Filipino Reporter states that "according to the January 2007 issue of Health After 50, as individuals age, the thirst response system diminishes so that the elderly may not feel thirsty even as dehydration is setting in"(2007, p. 1). The Journal of Applied Physiology published the results of a 2002 trial that compared the fluid intake of men aged 51-60 with men aged 20-28 after they all completed a strenuous 10 day hill- walking trip(Sibal, 2007, p 1). The hikers aged 20-28 kept rehydrating themselves with plenty of water and fluids, while the older men, with their decreased sense of thirst, became progressively dehydrated.
Disadvantage: Age related diseases and the medications the elderly must take for these diseases may also increase the risk of dehydration (Sibal, 2007, p. 2). Certain diseases that are more common in the eldery, such as kidney, diabetes, and thyroid disorders can all cause the body to excrete more water, which also will increase the risk of dehydration. Medications for hypertension such as diuretics, ACE inhibitiors, antipsychotic drugs and cholinesterase inhibitors that are used to treat Alzheimers’s disease and other dementia related illnesses can also cause increased water loss resulting in dehydration.
Intervention 2 Include foods in the diet that have a high water content. Such as fresh fruits, vegetables, watermelon (which is almost all water), yogurt, or even jello.
Disadvantage 1 According to the Journal of Rehabilitation Research and Development, "swallowing problems (dysphagia) can occur at any age but are most prevalent in elderly individuals and are a growing healthcare concern as the geriatric population expands"(Robbins, 2002 p. 543). If dysphagia is not treated or diagnosed early enough it can lead to dehydration, malnutrition, a reduction in the rehabilitation process after injury or illness.
Disadvatage 2 "Malnutrition, weight loss, and dehydration experienced by nursing home elders constitute a large and silent epidemic in the United States"(Sibal, p. 1). According to the Journal of Nursing Care Quality a elderly person that lives in a nursing home is more likely to suffer from dehydration resulting from inadequate fluid intake (Dyck, 2007, p. 59). Research suggests that the quality of nursing care that the elderly receive is greatly effected by the total number and types of nursing staff available to provide care to the residents (Dyck, 2007, p. 59). Even though federal law requires that facilities employ sufficient nursing staff to ensure the quality care for each resident of a nursing home, "loosely written regulations give nursing home operators great latitude in defining "sufficient staff" for their facilities" (Dyck, 2007, p. 59).
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