by Mary D. Litchford , PhD, RD, LDN
Have you heard more talk about hydration lately? Is your administrator concerned about residents’ hydration status like never before? Dehydration deficiencies are on the rise as state surveyors’ focus on nutrition –related regulations. Dehydration is a serious and deadly diagnosis –especially for chronically ill or frail adults.
Facts About Fluids
What is your favorite fluid? Water is base ingredient for most beverages. Plain water is favorite fluid for many adults. It not only quenches thirst, it’s an essential nutrient instrumental to healthy lifestyles.
Water is the most abundant compound in the human body. In ancient medical writings, Hippocrates stated that older adults showed a decline in total body water and even declared that this loss of body water was the cause of all symptoms of aging. Contemporary medical writings agree that total body water declines with age, but not that this change causes all symptoms aging.
The adult human is more than 50 percent water by weight. At birth, a newborn is about 75 percent water by weight. However, with age, the percentage of water decreases to 50 percent or less. The reason for the difference in total body water in younger vs. older adults is a decline in muscle mass and a rise in body fat that naturally occurs with aging. The clinical significance of differences in total body water at different ages is that older adults can become dehydrated more quickly than younger adults because their usual total body water is lower.
Water is vital for normal body functions. All nutrients are either dissolved or suspended in water for transport to body tissues and for cellular reactions. Water serves as a building material for growth and repair of the body. It functions in the digestion, absorption, circulation, and excretion.
Substances containing water act as lubricants around bones and joints. Water-soluble substances in saliva bind chewed food into a slippery bolus that slides easily through the esophagus without damaging any tissues. Saliva also coats the mouth, throat, and esophagus to prevent food from having direct contact to cells lining the oral cavity.
Water plays an important role in maintaining normal body temperature. The circulatory system carries core heat toward the skin’s surface. Since heat always travels from hot to cold, the body heat is carried away as the cooler outside air passes over skin. If the core body temperature continues to rise, the sweat glands secrete perspiration to the surface of the skin as another way to release heat. A warm dry breeze will evaporate sweat into water vapor, cooling the body. However if the air is humid, perspiration cannot evaporate into water vapor because the air is already saturated.
Hydrated and Healthy
In healthy adults, the regulation of body water is very precise. Even small losses of body are compensated for within 24 hours. However, the very young and very old are not able to make up for body water changes as easily and are at greater risk for dehydration. Inadequate intake of fluids leads to dehydration, a condition that occurs when the body does not have enough water to carry out normal functions. Even mild dehydration can result in fatigue, apathy, and even subtle changes in mood. Risk factors for older adults can be categorized as:
Normal changes with aging:
• Advanced age
• Low body weight and low total body water
• Declining ability to concentrate urine
• Inadequate thirst response
• Functional losses
• Poor mobility
• Comprehension and community problems
• Partial or total assistance required to drink
• Altered taste perception
• Change in healthcare setting
• Insufficient caregivers
• Insufficient skilled caregivers
• Room temperature is too hot
• Alzheimer‘s and other forms of dementia
• More than five chronic diseases
• Fluid losses (diarrhea, fever, vomiting, bleeding, draining wounds, polyuria)
• Reduced oral intake (dysphagia, anorexia, confusion, depression)
• History of dehydration or unexplained weight loss
Healthcare interventions that may increase the risk for dehydration
• Highly concentrated protein supplements
• Dietary restriction of fluids
• Thickened liquids
• Medications (laxatives, diuretics)
• NPO for medical tests
Hydration is so important that the CMS Regulations specifically address it in F-tag 309.
F-327 Hydration – The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.
F-309 Quality of Care – Each resident must receive, and the facility must provide, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
Healthcare facilities must have effective policies in place to meet the expectation of F-327 and F-309. On going monitoring of these policies is vital to ensure that needs are being met. These guidelines are difficult to achieve in medically complex situations and in end-of-life care. Individuals who are very frail and are medically declining may experience episodes of illness associated with dehydration.
How Much Fluid is Needed Daily?
Estimation of fluid needs is a controversial topic and research on adequate fluid intake of elder is limited. The traditional recommendation of 6-8 cups of water/day has been replaced by the National Academy of Science’s (NAS) Adequate Intake levels. See Table 1. The total water recommendation includes water from foods and beverages. It is estimated that approximately 20 percent of fluid needs is met by food.
NAS Adequate Intake: Total Water
19-50 years Males 16 cups; 3.9 liters Females 11.5 cups; 2.8 liters
51-70 years Males 16 cups; 3.9 liters Females 16 cups; 3.9 liters
Over 70 years Males 13 cups; 3.2 liters Females 9 cups; 2.2 liters
For example, a 75 year-old female would need about 7 cups of fluids, with the balance of met by water in foods.
Numerous equations have been proposed and cited in professional references as valid methods to estimate fluid needs. However, there is no compelling evidence to validate the use of any of these equations. CDMs must work collaboratively with RDs and other members of the healthcare team to look for physical signs and symptoms of dehydration. Some warning signs and symptoms associated with dehydration include:
• Low blood pressure
• Low urinary output or dark urine
• Abnormal lab test results
• Change in cognitive status
• Increased assistance at meals required
• Diarrhea and/or vomiting
• Dry mucous membranes
• Dry sunken tongue
• New infection
• New medications that promote fluid loss
• Excessive urination
• Skin breakdown
• Sunken eyes
• Dizzy when sitting/ standing
These warning signs can signal a significant change in medical status and may need to be addressed by the physician. Update care plans as deemed appropriate. Keep families abreast of significant changes in medical condition as well.
Care plans needs to address reasonable goals with effective strategies to prevent dehydration or treat dehydration. Do not assume that dehydration must trigger in order for hydration to be a problem. Also, medical conditions change rapidly. Pay attention to changes that impact fluid intake or promote increased fluid losses.
Be creative in ways to increase water intake such as using flavored waters, carbonated water, bottled water juice tea blends, and flavored hot beverages. A good way to see if residents will like a new beverage is to offer a small portion at a theme meal as an appetizer or serve at an activity. Add some pizzaz to the event by serving each table like a waiter in a fine restaurant or at fancy party. That way you will hear compliments and complaints about the new beverages first hand. Be sure to prepare thickened beverage samples for residents for who cannot tolerate thin liquids. Seek suggestions from families, staff, and residents for other ideas.
Remember that fruits and vegetables have a high water content. Frozen fruit bars, yogurt fruit smoothies, fruit slushies, cold pureed soups sherbets and sorbets are high fluid items. Be sure that the items you add for more fluid are consistent with other dietary restrictions.
During meal rounds, pay close attention to individuals who drink less than 8 ounces at a meal, are picky eaters, those who complain about the taste of foods, and to those on thickened liquids. Also, medications can alter taste perception giving some beverages, including plain water, a metallic taste. If early satiety is problem, work with nursing staff on offering fluids every 2-3 hours. Provide assistance at meals for individuals who are dependent feeders. Be sure to document all efforts, including discussions with family members.
Implications for Practice
Hydration management can be difficult for individuals with complex medical conditions. Give special attention to picky eaters those on thickened liquids, and individuals with altered taste perception. Adding more fluid each day may be more challenging for these individuals. Solicit family members to help encourage fluid intake.
If meeting fluid needs through oral intake is unsuccessful, more aggressive hydration support may be considered. Collaborate with the healthcare team to notify families of potential risks and benefits of IV hydration or tube feedings to maintain adequate hydration. Allow families time to consider different options and to discuss the matter with members of the healthcare team.
Mary D. Litchford, PhD, RD, LDN is a nationally recognized speaker and the author of various articles and books, including Common Denominators of Declining Nutritional Status.
1. American Medical Directors Associated (2001). Dehydration and fluid maintenance: CPG. Columbia, MD; ADMA.
2. Litchford, MD. Common Denominations of Declining Nutritional Status, Greenboro, NC: CASE Software &Books, 2009.
3. Jéquier E, Constant F. Walter as an essential nutrient: the physiological basis of hydration. European Journal of Clinical Nutrition(2010)64, 115/123