The Importance of Water

Next to oxygen, water is the nutrient most needed for life. A person can live without food for a month, but most people can survive only three or four days without water. All of us start life in a watery cradle of amniotic fluid and to this day remain water's creature. Water makes up 85% of the blood, 70% of the muscles and about 75% of the brain, and is present in and around each of our cells.

In the body, water acts as a solvent, coolant, lubricant, and transport agent. It's needed to regulate body temperature, carry nutrients, remove toxins and waste materials, and provide the medium in which all cellular chemical reactions take place.

Fluid balance is vital for body functions and adequate blood volume. A significant decrease in the total amount of body fluids leads to dehydration. Dehydration occurs when the amount of water you take in is less than the amount you are losing. Fluids can be lost through the urine, skin, or lungs. Along with fluids, essential electrolytes, such as sodium and potassium, are also perilously depleted in a dehydrated individual.

Dehydration and the Elderly

Elderly individuals are at a heightened risk for dehydration because their bodies have a lower water content than younger people. An elderly person weighing 150 pounds has about seven liters less water than a young person of the same weight. As a result of this lower water content, elderly individuals can become dehydrated more quickly.

Because of visual, cognitive, or motor impairments, elderly persons may have difficulty getting fluids for themselves. They also may have only a muted perception of thirst. Unfortunately, many symptoms of dehydration do not appear until significant fluid has been lost. Practitioners in the field know that dehydration can happen very rapidly, in less than an eight-hour shift. The consequences of dehydration among the elderly can be life threatening and the symptoms are alarmingly swift.

Nursing facility residents are particularly at risk for dehydration. According to the article "Preventing Dehydration in the Elderly" published in the September 1996 edition of Provider magazine, as many as 75 percent of residents have average fluid intakes below 1,500 cc per day, while a minimum recommendation is between 1,500 to 2,000 cc of fluid intake per day. These residents may need more opportunities and reminders to drink. Those with disabilities may be unable to get a glass of fluid without assistance. However, disability is not the only risk factor. Residents who are not dependent on staff also need encouragement for sufficient fluid intake.

Even when offered water, residents will refuse the offer because "I'm not thirsty" or "I've already had too much to drink today." Many elderly individuals also exacerbate their risk of dehydration by limiting their fluid intake in the incorrect belief that they will prevent incontinence and decrease the number of needed trips to the bathroom. Residents and staff should be taught that decreasing fluid intake does not decrease incontinence, nor does it decrease trips to the bathroom. In fact, as the urine becomes more concentrated, it irritates the bladder and may increase the urge to void resulting in frequent small voidings.

Signs and Symptoms of Dehydration

It is important that staff members be able to recognize the signs and symptoms of dehydration to promptly assure correction and prevention of complications. Without timely correction, dehydration can lead to decreased functional ability, predisposition to falls due to orthostatic hypotension, constipation, predisposition to infection, and death. According the chapter on "Dehydration: Prevention and Recognition" published by Long Term Care Educator, staff members should be alert to the following symptoms:

• Confusion can be an early sign of dehydration. Caregivers who work regularly with a resident may be best able to detect subtle changes in mental status that are present when dehydration develops. Dehydration should be one of the first problems suspected when a resident has a sudden change in mental status.

• Poor skin turgor (elasticity) accompanies dehydration, but this can be a difficult sign to assess because most older residents have an age-related reduction in skin turgor under normal circumstances. If skin turgor is to be used in assessing for dehydration, the best areas to test are the skin over the sternum and forehead because these areas maintain better skin turgor than other areas. Generally, skin will feel warm and moist with dehydration.

• An inspection of the oral cavity can yield useful insight into a resident's hydration status. A dry oral mucosa and dry furrowed tongue are good indicators of dehydration. Staff should be cautioned that residents who are taking certain medications (such as anticholinergic drugs) may have dry oral mucosas in the absence of dehydration.

• An assessment of vital signs will reveal a decrease in blood pressure and increase in pulse when dehydration is present.

• A review of bowel elimination patterns can assist in assessing dehydration. Recent diarrhea can offer an explanation for a dehydrated state, while constipation is a common occurrence when dehydration exists. Likewise, bladder elimination patterns can provide useful insights: excess voiding can contribute to dehydration while scanty output can indicate insufficient fluid intake. Concentrated urine is a common sign.

• Because such a large percentage of the body is comprised of fluid, weight loss is often present.

If any of the above symptoms are noted, steps should be taken as soon as possible to further assess the resident for dehydration and take corrective action as necessary.

Taking a Proactive Approach to Preventing Dehydration

The best defense against dehydration is prevention. Illinois Council facilities are utilizing a variety of proactive strategies to identify residents at risk for dehydration, monitor their fluid balance, and establish institutional policies and programs to ensure that all residents receive adequate hydration. The following are some of recommendations that have been suggested by Illinois Council homes:

• Routinely monitor residents for signs of dehydration such as cracked lips, dry oral mucous, poor skin turgor, and dark urine color. Observe the residents' consumption of fluids to determine if they have reduced the amount of liquids they usually drink. Pertinent observations should be recorded in the nursing notes.

• Keep a list of residents at high risk of dehydration in the nurses' station and other strategic locations to remind others to monitor residents' fluid intake. Consider placing a symbol, such as a drop of water, near the beds of those residents at risk of dehydration as a sign for staff members to encourage fluid intake.

• Establish hydration protocols to be instituted immediately when acute symptoms or illness threaten fluid and electrolyte homeostasis.

• Schedule fluid administration at least three times a day between meals. Older people tolerate frequent administration of fluid in smaller quantities better than infrequent larger quantities.

• To maintain hydration, note the residents' preferences for type and temperature of fluids, and individualize the hydration plan to encourage compliance.

• Review residents' medications to assess possible impact of fluid and electrolyte levels.

• Leave filled, fresh water pitchers at residents' bedside and assure that residents are able to easily reach pitchers and glasses. Supply straws and special drinking glasses to assist residents as necessary.

• Staff should offer a variety of fluids at a variety of times and tell residents what the purpose of this procedure is. For example, the dietary staff could add a glass of water to each meal. Activities such as discussion or music groups should include the offering of beverages.

• Arrange for residents to eat meals and have snacks with other residents. Residents typically consume more food and fluids in a social setting.

• Offer at least a full glass of fluid with medications. Studies have shown that residents tend to drink the entire amount of fluid offered.

• CNAs can offer small amounts of fluid every time they interact with a resident during care delivery; i.e., toileting, after a transfer, after getting dressed, after rehab or therapy or range of motion exercises.

• Instruct residents, staff, and families about the importance of hydration. Involve the resident and family in establishing and meeting hydration goals.

• Teach staff to use a direct, positive approach when administering fluids. Avoid asking: "Do you want something to drink?" Instead say: "Here is some cool, refreshing water for you Mrs. Jones." Older people may not feel thirsty and may not recognize their need for fluid.

• Consider giving residents water bottles (such as those used by athletes) to carry with them around the facility. On a regular basis, be sure to fill the residents' water bottles with their favorite cool beverages.

• Offer residents a variety of delicious beverages on a beverage cart. Have a staff member provide drinks from this cart to residents on a daily basis.

• Sponsor a cocktail hour for residents to enjoy their favorite beverages and socialize. Facilities might consider having a bar with different bottles and attractive colors where residents can come up and order their drinks.

• Make drinks more appealing by the use of "props" that are colorful and inexpensive, such as lemonade pitchers and glasses, cocktail decorations, or a fruit garnish.

• During activities, use a blender to mix juice combinations for the residents to enjoy such as kiwi and strawberry; vanilla and root beer soda; ginger ale in cranberry juice; and orange and pineapple juice.

• Ask the residents for their ideas on delicious drink ideas that can be created during activity programs. Consider the creation of frozen liquids such as lemon ice, popsicles, and gelatin desserts. Try developing a "juice bar" with a variety of juices, Italian ices, and snow cones.

• For residents with disabilities, the occupational therapist may be able to recommend self-help devices such as long flexible straws and spouted or two-handled cups. For residents with increased stiffness, commonly seen in the later stages of Alzheimer's disease, a cup with a cut-out on the upper rim for the nose allows the cup to be tilted enough for the resident to drink.

• Ask surveyors if they will offer something to drink to residents they interview during the survey, as part of the overall facility efforts to prevent dehydration.

• When offering fluids, avoid offering beverages that contain caffeine or alcohol since both have dehydrating properties.

• Educate families about the importance of promoting hydration while they visit in and/or out of the facility.

• Take ice water and other beverages on all outings and offer at frequent intervals.

• Before walking through the zoo, museum, park, etc. provide each resident with a personal water bottle. These are easy to carry and refill and should be marked with the resident's name before distribution.

• If residents refuse fluids on an outing, give them a salty snack. This will increase their tendency to accept a drink.

• Make sure that water fountains in the facility are low enough to facilitate use by residents in wheel chairs. Include a cup dispenser and wastebasket next to the drinking fountain. For easier use, adaptive "handles" can be purchsed to make dispensing easier.

Activity Ideas that Encourage Hydration

The activity professional is in a unique position to encourage residents to increase their fluid intake. The social structure of interactions used by these professionals offer many opportunities to offer "liquid refreshments" as a natural part of the activity. The following are some simple ideas to add to any current activity program:

• Decorate a cart and stock it with a variety of juices and water when making room visits. Begin the visit by sharing a beverage of choice. In many instances this will trigger fond memories of going to the soda fountain for a cherry Coke or sipping lemonade at a church picnic. This same idea can be utilized when staff or volunteers take the "library cart" from room to room.

• Incorporate a "juice break" into small group activities held on each floor or unit. The residents appreciate this time to rest and socialize with those around them.

• Use specific beverages as part of a reminiscing group. For example, have the group squeeze lemons and make lemonade. You'll be surprised at the many stories connected with this simple beverage.

• Have a "taste-test" and have the residents guess the flavor of the juice, soft drink, tea, coffee, shake, etc. they are drinking.

• Hold an afternoon "tea" where small groups can gather over a cup of tea or other beverages and just visit or discuss a specific topic.

• As the residents wait for the dining room to open, use the opportunity to provide a liquid appetizer such as tomato juice, orange juice, V-8 juice, etc.

• Have a Happy Hour before the evening meal and offer non-alcoholic drinks. Almost any mixed drink can be made without alcohol, i.e., a virgin Bloody Mary.

• Always have water and/or a variety of other beverages available when on outings or when sitting outside with the residents.

• Using "real" cups and glasses makes beverages more appealing; when living in the community, this is what the residents used.

• During cooking group, have glasses of water with floating slices of lemon and ice cubes at each resident's place when the activity begins. Keep refilling their glasses as the meal is prepared and eaten.

Dehydration in nursing home residents is a common and dangerous problem requiring the involvement of the entire interdisciplinary team. Every opportunity to encourage residents to drink should be used, not only by nursing staff, but dietary, activities, social services, volunteers, and family. By taking a proactive approach to preventing dehydration, staff members can make great progress in reducing unnecessary hospitalizations and maximizing resident health and well-being.