The challenge with hydration for the elderly
Seniors are at great risk of dehydration, particularly as inpatients. Ana Reisdorf, RD, talks through the risk factors, recommendations and solutions for this vulnerable group.
08 June 2020
Maintaining proper hydration is universally important, but those over the age of 65 are at greater than average risk for dehydration.
Prevention and quick amelioration of dehydration is a crucial component of care for the older adult.
Dehydration leads to a lack of water in the cells that correlates with an increase in osmolarity, or the concentration of solid particles outside the cells, which causes a cascade of negative effects.
Disruptions in water and electrolyte balance can lead to decreased muscle strength, renal failure, and increased risk of falls.1 In addition, dehydration has been linked to a decline in cognitive function and mood.2
For the elderly, dehydration poses a serious risk because it can happen faster than younger adults. This means that for the older population, proper hydration is necessary for mitigating these detrimental health effects.
Disruptions in water and electrolyte balance can lead to decreased muscle strength, renal failure and increased risk of falls.
Lorenzo et al. (2019)
Incidence of Dehydration in the Elderly Population
Conservative estimates put the prevalence of elderly adults that are currently dehydrated at 20%. The European Society for Parenteral and Enteral Nutrition (ESPEN) states that over ⅓ of aged adults in residential care facilities may be dehydrated.1, 3 In hospitalized patients, this statistic jumps as high as 40%.4
The cause of dehydration in older adults is multifactorial. As people age, thirst sensation reduces and thirst’s osmotic set point increases. This means that older adults will feel thirsty later and drink less than younger individuals.5
Another area of concern is the decline of the body’s ability to concentrate urine. In older adults, urine osmolality and the ability to conserve solutes decreases by 20% and 50% respectively.5, 6
Thus, elderly excrete a greater proportion of the water and electrolytes they consume, putting them at higher risk for dehydration.
Many common medications including steroids, diuretics, and antidepressants affect the renin-angiotensin-aldosterone system which controls body water, further complicating the ability to maintain water balance.1
These medications, often prescribed to elderly patients, increase the importance of proper hydration.
Over 1/3 of aged adults in residential care facilities, may be dehydrated1, 3
The European Society for Parenteral and Enteral Nutrition (ESPEN)
Of aged adults in hospital care, may be dehydrated4
The European Society for Parenteral and Enteral Nutrition (ESPEN)
Approaches to Hydration
Physiologic mechanisms in the elderly present a barrier to the prevention and treatment of dehydration. Every ounce of fluid counts, but some fluids work better than others for rehydration.
When fluids contain electrolytes, such as sodium and potassium, the electrolytes help the body absorb fluids more efficiently compared to just drinking plain water.
The body has a specific formula of water and electrolytes it prefers for more efficient hydration, not found in water.
Sports drinks might seem like the best choice but in a trial studying the hydration power of different beverages, sports drinks provided no more benefit than plain water, coffee, or juice.7
What did work best for hydration in this study? Oral rehydration solutions (ORS) and milk. These beverages have the highest tonicity and a beverage hydration index (BHI), which helps to move fluids into the cells for hydration because they contain more electrolytes than other drinks.7
Although this particular study did use younger subjects, the average age was 25, it appears that higher tonicity drinks, such as an ORS and milk, may be closer to the body’s ideal rehydration fluid.
While all fluids can help prevent dehydration, higher-tonicity beverages are closest to the body’s ideal drink and provide the patient with greater benefit per ounce.
It is recommended that elderly men consume 13 cups (3 L) of fluid daily and elderly women consume 9 cups (2.1 L) of fluid daily to recoup water losses and stave off dehydration.3
But this recommendation for daily intake includes fluid that is consumed though food. ESPEN recommends that older women be offered at least 7 cups (1.6 L) and men be offered 8.5 cups (2.0 L) of beverages per day.8
Functional waters, jellies, and juices containing nutrients such as proteins and minerals provide the older adult with the greatest hydration benefit per ounce
Ana Reisford, MS, RD
High Protein Juice
Registered Dietitian Nutritionist
Ana Reisdorf, MS, RD is a Registered Dietitian Nutritionist and freelance writer with 12-years of experience in the field of nutrition and dietetics.
- Osmolarity: The concentration of solute particles (such as sodium) per liter of fluid
- Hyperosmolar: Having a high osmolarity
- Osmolality: The concentration of solute particles per kilogram of fluid
- Tonicity: measure of the osmotic pressure gradient, which determines the direction fluids will move
-  Lorenzo I, Serra-Prat M, Yébenes JC. The Role of Water Homeostasis in Muscle Function and Frailty: A Review. Nutrients. 2019;11(8):1857. doi:10.3390/nu11081857
-  Masento NA, Golightly M, Field DT, et al. Effects of hydration status on cognitive performance and mood. British Journal of Nutrition. 2014;111(10):1841-1852. doi:10.1017/s0007114513004455
-  Volkert D, Beck AM, Cederholm T, et al. ESPEN guideline on clinical nutrition and hydration in geriatrics. Clinical Nutrition. 2019:38:10-47. https://doi.org/10.1016/j.clnu.2018.05.024
-  Fortes MB, Owen JA, Raymond-Barker P, et al. Is This Elderly Patient Dehydrated? Diagnostic Accuracy of Hydration Assessment Using Physical Signs, Urine, and Saliva Markers. Journal of the American Medical Directors Association. 2015;16(3):221-228. doi:10.1016/j.jamda.2014.09.012
-  Tamma G, Goswami N, Reichmuth J, et al. Aquaporins, Vasopressin, and Aging: Current Perspectives. Endocrinology. 2015;156(3):777–788. https://doi.org/10.1210/en.2014-1812
-  Cowen LE, Hodak SP, Verbalis JG. Age-associated abnormalities of water homeostasis. Endocrinol Metab Clin North Am. 2013;42(2):349‐370. doi:10.1016/j.ecl.2013.02.005
-  Maughan RJ, Watson P, Cordery PA, et al. A randomized trial to assess the potential of different beverages to affect hydration status: development of a beverage hydration index. The American Journal of Clinical Nutrition. 2015;103(3):717-723. doi:10.3945/ajcn.115.114769
-  DRI Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate: Water. The National Academies of Science, Engineering, and Medicine. Washington, D.C.: National Academy Press; 2005;147-150.