A person can live without food for a month, but most people can survive only three or four days without water.
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 of fluid 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.

When a person is dehydrated, it is more difficult to maintain adequate blood pressure, deliver sufficient oxygen and nutrients to the cells, and eliminate wastes. Some of the common symptoms of dehydration include:

• Constipation. A hard, marble-like stool is often a sign of chronic poor fluid intake.
• Change in mental status. Confusion, irritability, or lethargy may be signs of a more acute problem.
• Increased weakness.
• Dry tongues, lips, and mucous membranes. No pool of saliva under the tongue.
• Dark, strong-smelling urine.
• Poor skin elasticity (the ability of the skin to stretch and return to normal). To assess skin elasticity, gently pinch the skin over the sternum (breastbone) or forehead. If the skin remains "tented," that could be a sign of dehydration.

In a study published in the August 1994 issue of the American Journal of Public Health, researchers from the federal Department of Health and Human Services found that dehydration was a common cause of hospitalization and death among the elderly. Their study indicated that dehydration is one of the ten most common causes for hospitalization among Medicare patients. Nearly 197,000 Medicare recipients were hospitalized with dehydration as a principal diagnosis in 1991, costing Medicare more than $446 million in hospital payments. Most importantly, the study revealed that about half of the people over age 65 who are hospitalized with illnesses accompanied by dehydration die within one year of admission.

Most staff members think about the dangers of dehydration during the summer months, when residents can become susceptible to heat-related illnesses. However, the study reveals that 25-30 percent of all cases of serious dehydration result from pneumonia and flu, which peak during the winter months. As Dr. Joan Warren, one of the study's authors, states, "Your fluid intake needs to be increased when you have a fever or any kind of respiratory illness, so it's extremely important to drink lots of liquid when you're sick, even if you don't feel thirsty."

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 8 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. 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 a 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 may nevertheless need encouragement for sufficient fluid intake.

Many elderly individuals 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.

The best defense against dehydration is prevention. Prevention of dehydration can be accomplished effectively by identifying residents at risk for dehydration; monitoring their fluid balance closely.  Many of these suggestions are from the March 27, 1995 issue of the Brown University Long-Term Care Quality Letter and from Barb Lupo, RN, of Forest Villa Nursing Center:

• 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 residents have reduced the amount of liquids they usually drink. Pertinent observations should be recorded in the nursing notes in the residents' medical records.
• 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 high risk of dehydration as a sign for CNA's to encourage fluid intake.
• Schedule fluid administration at least three times a day between meals. Older people tolerate frequent administration of fluid in smaller quantities better than infrequent large quantities.
• Consider the following items from the MDS in identifying residents who are at risk for dehydration: deteriorated cognitive status (section B); deteriorated ADL status (section E); failure to eat or take medications (sections L and O); health conditions such as diarrhea or fever (section K). Specific identification of dehydration as a problem is noted in section L3.
• Review residents' medications to assess possible impact on fluid and electrolyte levels. Be especially alert to laxatives, which are used by 40 to 60 percent of elderly nursing home residents.
• Offer at least a full glass of fluid with medications. Studies have shown that residents tend to drink the entire amount of fluid offered.
• To maintain hydration, note the residents' preferences for type and temperature of fluids, and individualize the hydration plan to encourage compliance.
• Instruct residents, staff, and family members about the importance of hydration. Involve the resident and family in establishing and meeting hydration goals.
• Arrange for residents to eat meals and have snacks with others. Residents typically consume more food and fluids in a social setting. Be sure to offer beverages during all activity and therapy programs.
• Provide good oral hygiene to encourage consumption of fluids.
• Instruct 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.
• CNA's could offer small amounts of fluid every time they toilet a resident. One CNA could be assigned to make regular rounds with a beverage cart to offer fluids and assistance with toileting.
• Nursing staff can leave fluids at the residents' bedsides and offer milk as a first line of defense against insomnia.
• 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.