At the retirement community where Helen Rollins lives, 10 residents were hospitalized last year for a problem that seems easily prevented.
The seniors, all independent-living residents of a retirement community in Salt Lake City, were dehydrated and exhibited symptoms of urinary tract infections, one of the leading causes of emergency-room visits by older adults, she said.
In a nation awash with potable water — including the 12.8 billion gallons sold in bottles in 2016 — it seems strange that Americans of any age could be dehydrated. Yet some studies suggest that a third of seniors are chronically dehydrated and unaware that the condition may be responsible for health problems such as dizziness, confusion and constipation.
The solution, however, is not as simple as it seems. In America, chronic dehydration is not usually caused by the unavailability of water, but by a confluence of factors that include diuretic medicines, decreased thirst perception and other changes in the aging body.
There's also another, more heartrending reason: Many seniors don't drink enough because they fear the difficulty of getting to the bathroom and the risk of falling, especially during the night.
That creates a loop of health risks, however, since dehydration can make seniors more likely to fall, and falls are the leading cause of injuries among American seniors, according to the Centers for Disease Control and Prevention.
"This is a big problem. Some patients won't even take their diuretic medications during the nighttime because it makes them get up during the night and disturbs their sleep. Similarly, they won't drink later in the day because they don't want to get up during the night when it may be more difficult to ask for help," said Dr. Peter Abadir, a physician specializing in geriatrics who teaches at Johns Hopkins University School of Medicine in Baltimore.
While there's no easy solution to this complex problem, there are ways that families can help to ensure that their eldest members don't suffer the effects of chronic dehydration, which include confusion, weakness, constipation, headache, dizziness, reduced skin elasticity and in extreme cases, organ failure.
But the first thing to do is to learn how much water an older adult needs, and how much your loved one is now drinking.
The aging regulator
The human body is composed primarily of water, but the amount diminishes as we age. Infants are 70 to 75 percent water; teenagers, 60 percent. By old age, the proportion has dropped to around 50 percent, in part because the kidneys’ ability to retain water decreases with age.
But this alone doesn’t cause dehydration in the elderly, Abadir said. “A large percentage of our older adults are placed on medications that increase water loss to manage heart failure and blood pressure. Also, some of the medications taken for constipation and mood/depression disorders lead to increased water loss,” he said.
Meanwhile, the aging body is less able to perceive thirst. The sensation of thirst originates in the hypothalamus, an almond-sized part of the brain that regulates body processes. Stroke victims whose hypothalamus is affected may totally lose the ability to know if their body needs water.
Scientists aren’t sure why the perception of thirst declines in people who haven't suffered a stroke, but say that not knowing when the body is dangerously low on fluids is one reason so many elderly people die during heat waves. Human beings can go for more than three weeks without food, but less than a week without water, which is why some people attempt suicide by refraining from eating and drinking, trying to achieve "terminal dehydration."
But it's not just bodily functions that contribute to chronic dehydration in the elderly.
“Decline in cognition is also a major contributor, and is a challenge that puts the burden on caregivers to stay on top of hydration status in older adults,” Abadir said.
The problem is so widespread that a number of law firms specialize in legal action against nursing homes when dehydration contributes to a death.
How much do we need?
The amount of water people need is a subject of debate. The common standard of eight 8-ounce glasses a day has been largely debunked, but there is no universally accepted figure to take its place.
The National Academy of Medicine suggests 125 ounces (3.7 liters) a day for males and 91 ounces (2.7 liters) for females, but that recommendation is for total water intake, including water obtained from food. Most people get 20 percent of their water from food, 80 percent from beverages, Abadir said. Some physicians calculate an individual’s water needs by the person’s weight; everyone’s needs are different.
At minimum, older adults should aim to drink four ounces every four hours that they’re awake, said Dr. Bruce Naughton, a physician in Buffalo, New York, and a vice president of Excellus BlueCross BlueShield. “If you drop below that, dehydration can build up over two to three weeks. It’s a slow loss of water, and most people don’t realize that it’s happening until they fall,” he said.
Naughton noted that 1 in 5 falls result in a serious injury, such as a broken bone or head injury, and that a serious fall is a “game changer” for seniors, not only because of the injuries they sustain, but because they fear falling again. “People become less mobile, and it triggers a downward cycle,” he said.
Even if a person doesn’t feel thirsty, there are outward signs of dehydration, which can include irritability, exhaustion, dark urine, a dry mouth and tongue, and decreased urine and tears. In severe cases, a chronically dehydrated senior may also have low blood pressure and a weak pulse.
Another way to test for dehydration is to perform a skin "recoil” or “turgor” test like medical professionals do. To do this, pinch a fold of skin on the forearm or hand and watch how quickly it returns to normal. If the skin is slow to flatten and remains in the form of a tent, the person may be moderately or severely dehydrated. (You can also check for dehydration in a pet by using this method.)
Ways families can help
In the hospital, dehydration is often treated with intravenous fluids. Before it gets to that stage, there are several strategies that families can try to help a senior get enough to drink.
Abadir recommends developing a water schedule similar to a schedule for taking medicine.
“Reminders and prompts using smartphones or devices can be helpful, (as well as) putting water, or preferred beverages, in close proximity to adults throughout the day, and using the medication schedule as an opportunity to take water,” he said.
Another thing that can help is to focus on the mobility issues that can cause a senior to not drink enough because they don't want to go to the bathroom. Naughton said that a half-hour of light exercise five times a week can help sustain mobility, and that the exercise doesn't have to be vigorous. Something as simple as marching in place while brushing your teeth can help, he said.
Also, seniors and their caregivers should arrange their living quarters to make the bathroom well-lit and easily accessible, removing anything that could contribute to a fall so the person is more confident in her ability to get to the bathroom when needed.
Common hazards include throw rugs, clutter, unstable chairs and tables, and extension cords that lie across walkways, according to Naughton. Seniors and their caregivers should also be aware of dim lighting and pets that lie down or follow a person who is walking.
Families should also talk to a senior at risk for dehydration about what beverages they most like to drink. While water is generally thought to be the most effective, a study published last year in the American Journal of Clinical Nutrition showed that other beverages — including milk — are effective hydrators that may not result in as much urine output as water.
British researchers tested 72 men to see how long different types of fluid remained in their bodies. They found that milk (both whole and fat-free), orange juice and commercial rehydration fluids such as Pedialyte stayed in the body longer than water. The subjects, however, were all in their 20s, so it's uncertain whether similar results would occur in seniors.
While diabetics should stay away from juices, most beverages are fine, so long as they don't contain caffeine, Naughton said.
The CDC, meanwhile, suggests providing seniors with foods that have high water content, such as lettuce, watermelon and broccoli, and serving broth soups.
A positive change
As for the urinary-tract infections that sent so many Rollins neighbors to the emergency room, Abadir says that many people who seem to have UTIs are actually just dehydrated.
For years, it was thought that dehydration causes an overgrowth of bacteria in the urinary tract since the bacteria are not frequently flushed from the body, but some health experts now believe that concentrated urine actually reduces bacterial growth.
"Sometimes it is the increased acidity/concentration of urine that you get with dehydration that makes the older adult get the burning-on-urination sensation," Abadir said. "On urine analysis, you will see some bacteria that would trigger an antibiotics prescription, though drinking water may have been all what is needed."
Meanwhile, Rollins, a retired nurse who, at 73, is the youngest resident in her community, has been on a crusade to educate her neighbors about the dangers of dehydration. Now, when anyone complains of a symptom, no matter what it is, the others all say, "Drink some water."
And it seems to be working. None of her neighbors have been hospitalized yet in 2017. "We may be making progress," Rollins said.