A previous study reveals that the average individual discharged from the hospital with a diagnosis of dehydration is about 80 years of age, spends an average hospital stay of 4.6 days at estimated $1,628 per day.  Needless to say, your long term care residents are faced, not only with a costly predicament, but on-going need for preventive interventions.

According to a recent Journal of American Medical Directors Association article, dehydration refers to the “loss of body water, with or without salt, at a rate greater than the body can replace it”. It reveals that there are two types of dehydration: water loss dehydration (hyperosmolar due to either increase in sodium or glucose) and salt and water loss dehydration (hyponatremia).  A complete assessment of the resident’s history, clinical symptoms and laboratory testing is required to make appropriate diagnosis. The article also suggests that dehydration is seldom a cause of poor care or neglect but may be a combination of physiological and disease processes.  In either case, the article strongly suggests that the interdisciplinary health care team must focus on prevention of dehydration.

In order to develop and initiate a successful plan for preventing dehydration in your facility, every caregiver must first fully understand the causes, clinical symptoms, and risks or consequences of dehydration in your elderly population.

Causes of dehydration:

1. Physiological changes due to aging– decreased thirst sensation,  decreased kidney functions
2. Changes in functional and cognitive status – decreased mobility, dementia, swallowing problems, poor appetite, diminished vision, reduced taste sensation, impaired ability to communicate needs and seek water,  fear of continence
3. Diseases resulting to fluid losses -infections, fever, diarrhea
4. Other diagnoses that may cause poor oral intakes-depression, Parkinson’s, stroke
5. Medications – diuretics  (for example, Lasix) causing frequent urination

Clinical signs of dehydration:

1. Confusion/altered mental status
2. Speech difficulty
3. Dry tongue and mouth/cracked lips
4. Increased weakness
5. Decreased urine/concentrated urine
6. Sunken eyes

Risks /consequences of dehydration:

1. Changes in mental status
2. Constipation
3. Urinary tract infection
4. Functional decline
5. Poor skin elasticity
6. Pressure sores
7. Delayed wound healing
8. Delayed recovery from an illness
9. Frequent or extended hospital stay
10. Weight loss
11. Death

It is the obligation of the facility to educate staff members and monitor for any indication of dehydration among the residents.  A regular all- staff in-service is highly recommended for newly hired and current employees. Any changes in resident’s behavior, for example, confusion, and weight loss must be reported immediately to the appropriate staff member.

There are several ways your facility can implement dehydration prevention protocol:

1. Determine and assess residents who may be high risk for dehydration. A risk assessment tool may be utilized.
2. Estimate resident’s individual fluid needs based on current weight, diagnoses, and special needs at admission.  Chernoff’s formula of 30 ml per kilogram body weight with a minimum 1500 cc fluid per day may be used.  Fluid requirement may be adjusted based on diagnoses and obese status as calculated by the dietitian.
3. Develop hydration policies and procedures
4. Serve water every meal and in between. A variety of fruit /vegetable juices may be offered for extra hydration
5. Offer hot or cold beverages during social activity and therapy hours
6. Initiate a hydration cart with a variety of beverages and nourishing snacks
   and make it easily accessible to residents. Include thickened beverages for residents with thickened liquid orders.
7. Incorporate soup, gelatin, sherbet, popsicles or ice cream on your menus to increase fluid content of meals.
8. Include about 1200-1500 cc fluid on your menus
9. Offer extra fluids during medication pass.
10. Offer equal amount of water at each 2 cal supplement pass to prevent its dehydrating effect
11. Individualize resident’s hydration plan based on preferences to encourage   compliance
12. Staff member should offer resident beverages each time he/she enters resident’s room (except when resident is fluid restricted).
13. Evaluate residents’ ability to pour or drink liquids as well as to pick up cup or glasses.
14. Place bedside water pitcher and cups within resident’s reach
15. Use direct, positive approach when offering fluids to resident. Instead of asking, “Do you want something to drink?” say, “Here’s refreshing juice or fresh water for you.”
16. Regularly monitor fluid intake of residents.
17. Watch for signs and symptoms of dehydration in residents who may be at risk.

In conclusion, dehydration in the elderly is a serious concern in any long term care facility.  Dehydration in the elderly is not only debilitating; it affects their quality of life or may even cause death; therefore, it must be addressed and intervened appropriately by the interdisciplinary team without any delay or procrastination.