Hydration for the elderly in long-term care residences

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By Dale Mayerson and Karen Thompson

Water is essential for life and humans cannot live more than a few days without it. Water comprises about 50 to 70 per cent of human body weight and plays a role in almost every biochemical reaction.  Dehydration is defined as a harmful reduction in the amount of water in the body.   Dehydration is common with seniors in living in the community and can be an issue for those living in long term care.

Why are seniors at risk?

There are several factors that can increase the risk of dehydration for residents including: diminishing thirst sensation, decreasing ability to eat and drink independently, not asking for drinks, and the dehydrating effects of many medications. Residents may refuse to drink due to embarrassment related to urinary incontinence, while those with cognitive impairment may refuse drinks, even with cueing and encouragement.  Residents taking diuretics may also tend to stay in their rooms, since urine output can be more frequent than normal. Residents who have dysphagia are also at an increased risk of dehydration.  Thickened fluids are not as well-liked as thin fluids such as water or juice, and so not as much is taken.  Dehydration risk is most concerning when there is vomiting, diarrhea and fever, since water loss in these circumstances can be very high and fluids need to be immediately replaced.

Risks associated with dehydration

Dehydration for seniors can lead to an increased risk for falls. Since osteoporosis is a concern for many seniors, both men and women, the results of a fall can mean a fracture of a hip, or spinal column or wrist. This can change a senior’s entire life, leaving them less mobile, possibly in a wheelchair, with a greater need for assistance with activities of daily living, potentially requiring a change in living conditions.

Constipation is another concern for seniors, which can be related to a decrease in physical activity and less than adequate fibre in the diet.  Additionally other health concerns contribute to constipation such as stroke, Parkinson’s Disease,  hypothyroidism, diabetes, etc., as well as a side effect of many medications.  Poor fluid intake can also cause constipation or at least exacerbate the situation, since water intake helps to move stool through the large intestine.   Adequate fluid intake is important to alleviate this problem and is an essential part of prevention.   Residents with constipation may be uncomfortable which can also lead to involvement in fewer activities.

Skin health is maintained or improved with good nutrition and hydration.  Dry, thin, frail skin is more likely to break down and form open areas which can leak fluids, leading to greater risk of dehydration.

Dehydration prevention in LTC

Residents in long term care should be offered fluids frequently.  Meals should include water, juice, milk as well as coffee or tea.  Drinks are offered at snack times between meals, and smaller amounts are provided with medications and may also be offered at various activities and events in the home.  Estimated fluid needs are calculated based on residents’ weights, but appropriate intake for many is approximately a minimum of 1500 ml or 6 cups of fluids per day. This does not include high fluid foods such as soup, yogurt, fruits, vegetables and other foods.

Residents who are dehydrated are at greater risk of hospitalization and may require intravenous therapy. To avoid this situation, processes for adequate hydration should be implemented.

These may include:

  • Posting a list that identifies residents at risk of dehydration and updating this list frequently
  • Providing drinks every hour from a hydration cart for those at high risk
  • Making fluids readily available during hot weather so family, staff and volunteers can offer it to residents
  • Offering fluids frequently during meal and snack times (not just once), to maximize drinking opportunities
  • Offering sips between bites of food for residents being fed
  • Offering water with medications
  • Offering fluids after resident has used the toilet
  • Providing encouragement and assistance for meals and snacks as this has shown to improve intake
  • Starting a “sip and go” program so that anyone entering a resident’s room can offer a sip of water
  • Educating and training staff and volunteers to be aware of the need for fluid intake
  • Informing RN/RPN when there are warning signs for dehydration i.e. dark urine, increased confusion etc.
  • Increasing the monitoring of those residents at risk i.e. those with a history of dehydration, those on thickened fluids
  • Providing hypodermoclysis, or water provided subcutaneously (under the skin)
  • Maintaining a clear and simple system for documenting fluid intake that flags those residents that may be at risk

Hydration is a key part of good health and everyone working and visiting in long term care should be aware of their role in improving hydration status for residents.

Dale Mayerson B Sc RD CDE, and Karen Thompson, B A Sc RD are Registered Dietitians with extensive experience in Long-term care.  They are co-authors of “Menu Planning in Long Term Care and Retirement Homes: A Comprehensive Guide.”