Dehydration among elderly linked to increased disability and mortality: Study

UK: A recent study published in the journal Age and Ageing throws light on the importance of drinking water for older adults and the common misconceptions that are refraining them from doing so.

Staying hydrated is significant, especially in older adults, as dehydration can lead to negative health outcomes including increased risk of hospital admission, disability, infection, falls, acute ischaemic stroke and mortality. Still, studies have shown that somewhere between about one-third and one-half of older adults may be dehydrated.

Guidelines recommend that older people should drink regularly when not thirsty; older women should drink 1600 ml/day, older men 2000 ml/day; fluid intake should increase in people with weight loss, frail older people should be carefully monitored (particularly during heatwaves); water, juices, milk, and hot drinks all constitute hydrating fluids.

Little research has focused on the views of community-dwelling older people on hydration, healthy drinking and the perceived importance of drinking well in later life. Cini Bhanu, Department of Primary Care and Population Health, University College London, UK, and colleagues conducted the study to understand community-dwelling older people and informal carers’ views on hydration in later life and how older people can be supported to drink well.

For the purpose, the researchers interviewed 24 generally healthy people aged 75 years or older living in their own homes in north and central London in the UK. The interviewees were selected by age, gender, ethnicity and frailty status. People living in nursing homes and anyone receiving treatment for cancer or palliative care were excluded. People who could not provide consent or exhibited signs of dementia were also not included.

Four themes are presented: perceptions of healthy drinking, barriers to and facilitators of drinking in later life and supporting older people to drink well.

Key findings of the study include:

Perceptions of healthy drinking

• Self-reported drinking patterns varied amongst older people, some drinking little or infrequently in their daily routine. Many older people felt they were not drinking as much as they considered they were expected to.


• Perceptions of the importance of hydration were polarised. Some older people considered hydration as important and were able to recognize the potential risks of dehydration.


• In contrast, other people did not perceive hydration as important, could not appreciate the risks of dehydration and did not feel it was relevant to them.


• Most carers were knowledgeable of the consequences of poor fluid intake (citing urinary tract infections, delirium, and dehydration) and felt hydration to be a priority when caring for the older person.


• All participants were somewhat aware of overarching public health messages related to hydration (whether they perceived this to be important or not). The main sources of information were family, internet and the media. Many felt that advice was not directed at or relevant to them.


• Knowledge gaps were widespread. Many older people and carers were unsure how much fluid was appropriate. Ideas of a healthy intake ranged considerably from ‘seven cups’ to ‘three liters of water’ a day. Older people and carers often judged recommendations to be unachievable or inconsistent. Only one participant had received advice from their doctor and was confident about how much to drink.


• The importance of increasing fluid intake during periods of hot weather and acute illness was appreciated by most (even if they did not feel it be relevant at other times). Carers were acutely aware of this and encouraged the older person to proactively drink more under such circumstances


• Many older people themselves relied on their thirst increasing during such high-risk periods to facilitate drinking more.


• Most participants associated the term ‘hydration’ with water alone. Information on consumption of juices, hot beverages, and soft drinks required further probing.


• Attitudes to drinking choices varied. Some were mindful of the risks associated with sugary, caffeinated and carbonated drinks, restricting their fluid options.


• Many older people discussed enjoying alcohol. Older people expressed a nonchalant attitude to alcohol consumption, considering social benefit as an important factor and less worry about potential health risks. None of the older participants had discussed alcohol with their doctor.

Barriers to drinking in later life

• Concerns about urinary incontinence were a significant barrier to drinking, acknowledged by older people and carers. Many older people experienced a fear of incontinence leading to a highly restrictive pattern of fluid consumption. This was compounded by a lack of access to public toilets, and many older people avoided caffeinated drinks for this reason.


• Overreliance on thirst as a prompt to drink was described by many older people.


• Most were able to recognize that their fluid intake had decreased as they were aged, often alongside a reduced food intake, but could not describe the reason for this. With probing, most identified that their appetite had reduced as a cause for their reduced food intake but did not make the same link for diminished thirst and fluid intake.


• Older people with accumulating functional and cognitive impairments experienced greater challenges with drinking. Some described reduced mobility affecting their motivation to drink at home.


• Carers’ perspectives echoed these challenges. Many carers had noted gradual changes over time affecting the older persons’ functional capacity or swallowing, eventually impairing their ability to continue using the same kitchen equipment and receptacles.


• Carers for older people with cognitive impairments experienced difficulties monitoring their fluid intake. They found that offering regular prompts to drink were valuable but not always practical if they could not be presented for extended periods.

Facilitators of drinking in later life

• Whilst self-reported drinking patterns between individuals varied in terms of regularity, prompts and amounts, there were distinct habitual drinking patterns identified within individuals. Medications and mealtimes acted as the most consistent prompts. Two older people used these times to drink as much as they could, and many would not drink outside of these set times.


• Personal taste preference and variety were important to older people and carers to facilitate drinking well. Of the few older people who did report drinking regularly, many opted for juices and hot drinks in preference to water and enjoyed having options.

Supporting older people to drink well

• Few older people reported discussing fluid intake with a doctor. Of those who did receive medical advice about hydration, this advice was perceived as important, followed closely and led to greater awareness of the benefits of drinking well. However, this advice was only ever delivered in the context of being prescribed diuretic medication or whilst being treated for an acute illness related to dehydration in the hospital.


• Insights from carers highlighted the value of tailored home adaptations to support older people to drink. They felt that simple changes to support the older person’s independence were most appropriate although this topic should be approached sensitively.


• Carers emphasized the need for support at home. Some felt the greatest challenge would be the difficulty of changing deeply ingrained habits, together with inherent reservations on whether increasing fluid intake would have clear physical health benefits.

"Ideas for healthy drinking and perceptions of the importance of hydration vary. However, knowledge gaps and misconceptions are evident, including how much to drink, which fluids count and an overreliance on thirst as a driver. Fear of urinary incontinence and functional impairment are barriers; acknowledging taste preference and individual factors facilitate drinking well. Distinct habitual drinking patterns with medications and meals exist within individuals," wrote the authors.

"Older people and carers could be better supported to drink well. Building upon habitual factors using BCTs may be most promising, alongside tailored public health education. Multidisciplinary strategies may be most effective for complex older adults," they concluded.

The article, "‘I’ve never drunk very much water and I still don’t, and I see no reason to do so’: a qualitative study of the views of community-dwelling older people and carers on hydration in later life," is published in the journal Age and Ageing.

DOI: https://doi.org/10.1093/ageing/afz141