Clinical Concepts

Dehydration in the Older Adult

Hayley J. Miller, MSN, AGNP-C, CRNP

ABSTRACT
Dehydration affects 20% to 30% of
older adults. It has a greater nega-
tive outcome in this population than
in younger adults and increases
mortality, morbidity, and disability.
Dehydration is often caused by water
deprivation in older adults, although
excess water loss may also be a cause.
Traditional markers for dehydration
do not take into consideration many
of the physiological differences pres-
ent in older adults. Clinical assess-
ment of dehydration in older adults

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poses different findings, yet is not
always diagnostic. Treatment of de-
hydration should focus on prevention
and early diagnosis before it nega-
tively effects health and gives rise
to comorbidities. The current article
discusses what has most thoroughly
W ater is the most essential
nutrient required for the
maintenance of every body system.
age 70, total body water decreases
to 40% as compared to 60% in a
younger adult (O’Donnell, 2013).
been studied; the best strategies and It is vital for the removal of waste Due to a multitude of factors,
assessment tools for evaluation, diag- products as well as function of the including physical limitations,
nosis, and treatment of dehydration lymphatic, cardiac, gastrointestinal, poor accessibility, polypharmacy,
and urinary tract systems, and more. and cognitive impairments, older
in older adults; and what needs to be
Unfortunately, with age, total body adults do not consume the recom-
researched further. [Journal of Geron- water naturally decreases, causing mended amount of daily water
tological Nursing, 41(9), 8-13.] these systems to be less effective. By intake. The World Health Organi-
zation (WHO; 2009) recommends
ABOUT THE AUTHOR 2.2 to 2.9 liters for older women
Ms. Miller is Nurse Practitioner, Endocrine Oncologic Surgery, Penn Medicine, and older men, respectively; yet, in
Philadelphia, Pennsylvania. reality, the average individual older
The author has disclosed no potential conflicts of interest, financial or otherwise. than 70 drinks less than 1.5 liters
Address correspondence to Hayley J. Miller, MSN, AGNP-C, CRNP, Nurse Practi-
tioner, Endocrine Oncologic Surgery, Penn Medicine, 3400 Spruce Street, Philadelphia, per day (Thomas et al., 2008). With
PA 19104; e-mail: [email protected]. decreased total body water and
doi:10.3928/00989134-20150814-02 poor water intake, dehydration is a

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common condition in older adults loss through diarrhea, vomiting, or frequent. Unlike younger adults
and is often overlooked and not inadequate fluid intake. In all forms and children, the thirst response
treated. An estimated $5.5 billion of dehydration, the body innately is decreased and usually requires
of Medicare costs is spent annually increases the thirst mechanism. In a dramatic increase in osmolal-
for dehydration hospital admissions hypovolemic dehydration, where ity before it is triggered (Hooper,
(Xiao, Barber, & Campbell, 2004). there is a decrease in total body Bunn, Jimoh, & Fairweather-Tate,
Current clinical tools for assess- fluid, the renin–angiotensin system 2013). Vasopressin also decreases,
ments are generalized for all ages is activated and the kidneys start to disabling the capacity of the kid-
and do not take into consideration retain water and produce concen- neys to concentrate urine. Muscle
differences in older adults. The trated urine, and the thirst sensation can store a large amount of water,
American Medical Directors Asso- is also increased (Olde Rikkert et al., contributing to approximately 70%
ciation (AMDA; 2009) has updated 2009). Although forms of dehydra- of storage, whereas fat stores only
dehydration guidelines to include tion other than those presented in approximately 10% to 40% of
older adults in long-term care with the current article exist, isotonic and water. Older adults have decreased
reinforcement that dehydration hypertonic dehydration are the two muscle mass and increased adipose
cannot be clinically diagnosed. The most common among older adults tissue so they lose the added ben-
current article focuses on studied (Thomas et al., 2008). efit of a great water reserve (Olde
clinically significant findings in Mild dehydration, categorized as Rikkert et al., 2009).
dehydrated older adults, although water loss equivalent to 1% of body Often classic signs of dehydra-
the research is limited. The health, weight, can cause symptoms of tion look similar to natural, benign
safety, and quality of life for older headache, fatigue, weakness, dizzi- changes in older adults. Periorbital
adults is impacted by dehydration ness, and lethargy. Moderate dehy- areas appear sunken in many older
and its prevention, assessment, and dration may cause dry mouth, poor adults due to loss of subcutaneous
correction must take priority in urine output, rapid heart rate, and fat and collagen rather than dehy-
preventive care. decreased skin elasticity (AMDA, dration (Cheuvront et al., 2013).
2009). As dehydration progresses Skin naturally loses elasticity,
PATHOPHYSIOLOGY to a severe state, the body loses the causing poor skin turgor (Vivanti,
Dehydration begins with water ability to control its temperature. Harvey, Ash, & Battistutta, 2008).
loss or decreased water intake. With reduced hydration and blood Due to chronic obstructive pulmo-
Hypertonic dehydration, defined flow to the skin, the body is unable nary disease or other pulmonary
by a serum osmolality level to sweat or dissipate heat, usually diseases, as well as antihistamine
>300 mOsm/kg, is an increased presenting as fever. Decreased fluid use, mouth breathing is common
sodium concentration in the extra- volume can cause cardiac stress to and causes the appearance of
cellular fluid, which is often a result maintain blood distribution to vital dry mucous membranes, making
of diuretic therapy or inadequate organs. Decreased blood supply to physical assessment a challenge
fluid intake. In attempts to balance the brain often causes confusion and (Cheuvront et al., 2013).
osmolality, which is the measure impaired cognitive and coordination Incontinence, although not a
of the body’s electrolyte–water function. Decreased blood supply symptom of aging, is common in
balance, fluid is drawn from the to the kidneys in conjunction with older adults and can play a large
intracellular to extracellular fluid. little to no urination often result factor in the decision to purposely
This shift increases the osmolality in in kidney failure and urinary tract decrease fluid intake (Richards &
the intracellular fluid, which yields infections (Sands, 2009). Borglin, 2011). In older popula-
cell shrinkage and dehydration tions, dementia creates a scheme of
(Olde Rikkert, Melis, & Claassen, Age-Related Changes reasons for lack of hydration. Many
2009). Many natural changes occur older adults with cognitive impair-
Isotonic dehydration, defined in the body that are an inevitable ment may not be able to commu-
by a serum osmolality between part of aging. Instead of hydra- nicate their needs, including thirst.
285 and 295 mOsm/kg (which is tion homeostasis being an almost Facilities are often understaffed and
considered normal range), results effortless process, aging requires cannot provide sufficient attendance
from an equal excess loss of water more attention for maintaining this to residents to make sure that they
and electrolytes. Isotonic dehydra- balance. are given fluids throughout the day.
tion is seen in approximately 80% Older adults have a smaller It is a chore for individuals who are
of dehydration cases (Cheuvront, fluid reserve due to decreased total physically impaired and affected by
Kenefick, Charkoudian, & Sawka, body water; therefore, dehydra- arthritis to get up and retrieve some-
2013) and is often caused by fluid tion becomes more rapid and thing to drink (Mentes, 2007).

JOURNAL OF GERONTOLOGICAL NURSING • VOL. 41, NO. 9, 2015 9

 Taste bud capability decreases taking medication with high levels on rehydration would be required
with age, leaving primarily bitter of anticholinergic activity (Sura, for a clearer indication of dehydra-
and salty taste ability preserved Carnahan, Chen, & Aparasu, 2013). tion. This method of weight moni-
(Solemdal, Sandvik, Willumsen, Medications that are not neces- toring requires reassessment and
Mowe, & Hummel, 2012). Flavored sary, play a role in dehydration, or therefore can only be determined
water, tea, coffee and other hot alter taste should be discontinued after multiple visits (Hooper et al.,
drinks, milk, fruit juices, soft drinks, (Richards & Borglin, 2011). 2013). The assessments of weight
and alcohol account for 70% to Classic symptoms of dehydra- must be accurate and take issues
80% of fluid intake of individuals tion, including headaches, dizziness such as constipation and edema into
70 and older. Consuming high upon standing, dry mouth, diarrhea, account. Screening for dehydration
sugar, high sodium, and alcoholic and weight loss, should be inquired. will only pick up rapid dehydration
and/or caffeinated products can Change in body weight may be rather than a slow decline leading
further cause diuresis and fluid helpful in diagnosing rapid dehydra- toward dehydration.
shifts (Bellisle, Thronton, Hébel, tion. Water volume alters quickly Poor skin turgor is a classic sign
Denizeau, & Tahiri, 2010). in comparison to fat and muscle of dehydration, although this is an
mass, so that a substantial change expected finding in older adults.
CLINICAL PRESENTATION in body weight over a few days will One research study (Vivanti et al.,
History and Review of Systems relate most directly to fluid status 2008) suggests poor skin turgor of
A review of systems and daily (Hooper et al., 2013). the sternum as highly correlated
oral fluid intake are helpful in Self-reports of dry mouth may with mild to moderately dehydrated
diagnosing dehydration; however, be a sign that an older adult has older adults. To test sternal skin
this is often a challenge with older a cold and is mouth breathing or turgor, a provider can pinch an area
patients. Many older patients may it may indicate use of medication of skin above the sternum, hold for
not be able to recall a 24-hour fluid that causes dry mouth. Some blood a few seconds, and release. Poor
or diet intake or even the amount pressure medications, antihista- skin turgor will tent and take a few
of times that they typically uri- mine drugs, antidepressant agents, seconds to return flush with the skin
nate in a day. Many times, facili- diuretic agents, and nonsteroidal surface (Vivanti et al., 2008).
ties do not have the capability of anti-inflammatory drugs can cause As previously mentioned, dry
accurately measuring and tracking dry mouth. Chronic illnesses, such mucous membranes, although often
patients’ intake and output (Vergne, as rheumatoid arthritis or lupus, a sign of dehydration, can be tied
2012). Information on the types often also cause dry mouth (Vivanti to many other conditions or a side
of fluids (e.g., high sodium, high et al., 2008). effect of medications (Hooper et
sugar, caffeinated) can be helpful al., 2013). With 89% specificity and
in determining possible reasons for Physical Examination 44% sensitivity, a recent study of
change in osmolality and diuresis. Typical signs and symptoms 27 older adults clinically diagnosed
Difficulty drinking due to dys- of dehydration can be found on with dehydration showed that dry
phagia can also deter patients from physical examination, although axilla, dry mouth, sunken eyes,
drinking. Incontinence is often an many are also related to other delayed capillary refill, and upper
embarrassing subject, and many conditions. The constitutional signs body weakness were comparable
patients do not freely bring up the of dehydration often present as to diagnostic testing (Shimizu et
topic unless a health care profes- fatigued appearance, pallor, sunken al., 2012). Dentition should not be
sional addresses the issue first. periorbital areas, and chapped overlooked as poor oral health can
Medication review may be the most lips (Leibovitz et al., 2007). Tem- cause adverse taste sensation and a
important part of the history for perature may be elevated due to decrease in oral intake. Often sore
older patients. Polypharmacy often the body’s decreased capability gums or the necessity of dentures
can have a huge role in dehydration. to maintain homeostasis. Hypo- prevents adequate oral intake
Approximately 25% of patients tension and tachycardia are signs (Solemdal et al., 2012).
65 and older take a diuretic, which of hypovolemia, and orthostatic
can often play a large role in blood pressures should be col- Laboratory and Diagnostic Tests
excessive water loss (Kenkmann, lected to further assess for signs A plasma urea–creatinine ratio is
Price, Bolton, & Hooper, 2010). of hyponatremia or hypovolemia a great indicator of dehydration in
A U.S. analysis of medication (Sands, 2009). Weight loss 4% a healthy kidney, but older adults
expenditures showed that 23.3% of of body weight 7 days prior is often have a raised ratio related to
community-dwelling individuals indicative of water loss. Therefore, renal failure, bleeding, heart failure,
with dementia older than 65 were an increase of 4% of body weight sarcopenia, glucocorticoids, or

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high intakes of protein, making it TREATMENT AND Cloete, Dymond, & Long, 2012).
unhelpful in the specific diagnosis INTERVENTIONS Many patients with dementia also
of dehydration (AMDA, 2009). Due Nonpharmacological cannot communicate their needs
to the frequent and unnecessary Social, psychological, medical, effectively, including thirst and
screening and treatment of asymp- and environmental factors all toileting.
tomatic urinary tract infections in contribute to the amount of fluid The aesthetics of the environment
older adults, more providers are consumption (Köster, 2009). Due and associating drinking with social
refraining from using urinalysis; to the body’s natural changes that activities may improve intake. In
however, in the case of dehydra- occur with aging, including pos- facilities, smaller, home-like dining
tion, urinalysis may play an im- sible cognitive deficits as well as rooms may be more comfortable for
portant role. When dehydration is changes in physical surroundings, residents. Providing drinks during
suspected, urine can be collected a conscious effort must be made to social activities may result in a plea-
and assessed for a high specific increase oral hydration in the older surable correlation with drinking.
gravity and an amber to tea color. A adult population. The use of a favorite cup or mug for
urinalysis can further look for the Physical limitations, such as patients may also allow drinking
presence of leukocytes, nitrites, and being wheelchair-bound, make it to be more desirable. Having
blood to help identify if a urinary difficult for the patient to access a variety of drinks available in
tract infection may be causing an fluids, lift containers, or reach a facilities and in patients’ homes may
intentional decrease in water intake sink. Carrying heavy groceries, increase interest in drinking (Kant,
(Hooper et al., 2013). a task that fluids contribute to, Graubard, & Atchison, 2009).
Osmolality. Serum or plasma becomes a burden. Water coolers Daily intake and output logs are
osmolality is the gold standard to and dispensers are a great option for a calculated method of monitoring
diagnose dehydration. Osmolality older patients who reside alone or in for dehydration, although this is
change is sensitive enough to show a nursing home; they provide lower- usually not practical in a facility and
dehydration with only a 1% water level access and minimal to no is often difficult for older patients to
loss (AMDA, 2009). Sodium is physical exertion (Campbell, 2011). keep track of at home. Therefore, it
not as sensitive of an indicator as The use of bright red jugs in is useful to educate all patients and
osmolality and shifts typically do facilities has been shown to be staff on monitoring for early signs
not occur until moderate stages helpful as fluid reminders to staff of dehydration, including headache,
of dehydration. Serum osmolality and residents. Patients with bright fatigue, weakness, dizziness, and
>295 mOsm/kg can be indicative of red jugs alert staff that they are at lethargy. Recognition of dark urine
hyperosmolality and dehydration. risk of dehydration and the jugs and decreased or poor output, dry
The results are rapid and necessary should be filled at every opportu- mouth, and rapid heart rate should
to diagnose and support clinical nity. The bright red is also easy for alarm patients and staff that dehy-
findings, if any. To determine serum patients to see, as vision can decline dration has progressed.
osmolality, lab values for blood urea with age or dehydration and pale
nitrogen, serum bicarbonate, creati- cups are not easily visible (Hollis, Pharmacological
nine, glucose, sodium, calcium, and 2011). A small U.S. study of patients If there is an underlying cause for
potassium should be obtained. with Alzheimer’s disease showed an the dehydration, such as an acute
In the United States, more 83.7% increase of daily fluid intake illness or baseline dementia, the plan
than 25% of adults 65 and older with the use of a brightly colored of care in conjunction with rehydra-
have impaired glucose regulation cup (Dunne, Neargarder, Cipolloni, tion should be priority to the causal
(Kirkman et al., 2012). High serum & Cronin-Golomb, 2004). factor. If dehydration can be deter-
glucose will increase tonicity and In facilities, many residents do mined by 4% weight loss within
an increase in tonicity is also seen not ask for fluids other than at 7 days, AMDA (2009) strongly sug-
with dehydration, potentially meals because they do not want to gests an oral fluid prescription given
complicating diagnosis and testing. be a burden to the staff if they need over a 3-day period, in addition to
Overall, there are clear benefits help toileting. This is often seen in 1,500 mL of fluid daily. The specific
of using serum osmolality as a patients who experience urinary calculation to determine the amount
definitive diagnosis for water-loss incontinence. The priority in these of replacement fluid and the method
dehydration, as serum and intracel- scenarios is to incorporate frequent of implementation are shown in the
lular osmolality are central to body toileting and bladder training for Table.
fluid control, acting as a trigger to patients to feel comfortable asking After the 3-day rehydration, the
thirst and renal conservation of fluid for drinks throughout the day and patient’s weight should be approxi-
(Fluharty, 2002). to manage incontinence (Godfrey, mately identical to previous baseline

JOURNAL OF GERONTOLOGICAL NURSING • VOL. 41, NO. 9, 2015 11

 causes dehydration to be over-
TABLE looked or ignored. Available studies
CALCULATION AND IMPLEMENTATION OF FLUID REPLACEMENT (Leibovitz et al., 2007; Shimizu
Calculation Pre-illness weight (kg) – current weight (kg) = deficit (L)
et al., 2012; Solemdal et al., 2012;
Vivanti et al., 2008) focus on clinical
Implementationa findings of dehydration in older
% of Deficit adults rather than the biochemical
Day Replaced Concurrent Daily Maintenance (mL) diagnosis, likely due to staying in
1 50 1,500 the realm of realistic and manage-
able care for this population.
2 25 1,500
3 25 1,500 CONCLUSION
Currently, research is still needed
a
% of deficit replaced + concurrent daily maintenance (mL) = total daily intake (mL).
regarding dehydration in older
adults. Although studies exist that
identify clinical signs of dehydration
in this population, the evidence is
weight. This method is best for CLINICAL CONCERNS likely insufficient, and implementing
acute or abrupt dehydration, which Dehydration causes a multitude affordable and available biochemical
can often be seen with vomiting, of issues clinically and has a huge evaluation of older adults may be
diarrhea, a change in mental status, impact on quality of life for older the most accurate and best solu-
sudden dysphagia, or an acute illness adults. It is associated with many tion while more research is being
(AMDA, 2009). chronic health problems in older conducted.
Hyperdermoclysis is suggested adults, including falls, fractures, Considering the physiological
for moderate dehydration in an confusion, heat stress, constipa- changes with age that are inevitable,
outpatient setting, which allows for tion, urinary tract infections, kidney a screening tool must be catered to
primary care to treat and monitor stones, renal failure, drug toxicity, this population for dehydration to
dehydration without a hospital stroke, and poor wound healing be caught early and before it takes
admission. This method consists (Olde Rikkert et al., 2009). a toll on patients’ health. A tool for
of subcutaneous fluid replacement, Approximately 30% of adults this population may include the
which shows to be as effective as older than 65 and 50% of adults review of current headaches, dizzi-
parenteral replacement. Contrain- older than 80 experience at least ness when standing, and dry mouth;
dications to this treatment include one fall every year (WHO, 2009). the identification of anticholinergic
coagulation disorders and concur- Regarding dehydration, falls may medication use; and the inquiry of
rent anticoagulation (AMDA, 2009). be caused by orthostatic hypoten- quantity and types of fluids con-
For severe dehydration, AMDA sion and increased confusion and/or sumed daily, as well as a medical his-
(2009) highly recommends hospi- weakness. Incontinence in the older tory of diabetes and urinary inconti-
talization for fluid and electrolyte adult population can also lead to nence. The tool should also contain
replacement. In older adults, de- falls and may in turn discourage an assessment portion including at
hydration can cause death within adequate fluid intake. least blood pressure and weight.
days and is considered a medical Diverticulosis, which is common Primary care must include a focus
emergency. Signs of hypovolemic in 65% of adults 75 and older, often on the prevention of dehydration,
shock include cool and clammy causes chronic diarrhea (Toney, including recognition of early signs
skin, reduced urine output, flat Wallace, Sekhon, & Agrawal, 2008). and symptoms catered to an older
neck veins, altered mental status, Other common causes of diarrhea in population, support and treatment
and a low cardiac index, which older adults include antibiotic drugs, of causal comorbidities, and moni-
indicates a low circulating volume Clostridium difficile, and diabetes. toring of responses to treatment.
(Hooper et al., 2013). Hospital- As a result of dehydration, many Educating all staff, patients, and
ization for dehydration typically patients become constipated and family on early signs of dehydra-
means that other body organs have require harsh stimulant laxatives. tion may be helpful for patients
been detrimentally affected and, The current gold standard of who may be forgetful and mentally
as a result, 17% of older adults dehydration diagnosis relies on and/or physically impaired. Pre-
hospitalized for dehydration die biochemical confirmation, which vention of dehydration can cease
within 30 days (Waikar, Mount, & is often not feasible or accessible to an entire cascade of future health
Curhan, 2009). many older adults, and therefore problems, which can be a burden

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physically to the patient and eco- (2009). Intakes of plain water, moisture Y., Kanai, T., Kobayashi, H., & Tokuda,
in foods and beverages, and total water Y. (2012). Physical signs of dehydration in
nomically to the health care system. in the adult US population—nutritional, the elderly. Internal Medicine, 51, 1207-
Better understanding of fluid meal pattern, and body weight cor- 1210.
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sary for preventive measures and tion Examination Surveys 1999-2006. Mowe, M., & Hummel, T. (2012). The
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