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Hydration can decrease acute confusion and delirium (AANC, 2016 and Mentes et al, 1999) and help prevent cardiovascular issues such as stroke and coronary heart disease (Rasouli et al, 2008 in AANC, 2016). Some studies observe headache and irritability as an effect of water deprivation (Blau, 2005). Dehydration is the cause of hospitalization in many patients and is often linked to infection (Ferry, 2005). Even short term prolonged nothing by mouth (NPO) status before elective surgery has been correlated to an increased risk of dehydration, headache, irritability, hunger, and hypoglycemia in surgical patients (Smith, et al, 1977). In 2011, the American Society of Anesthesiologists stated patients may safely consume clear liquids up to 2 hours before elective surgery using general anesthesia.

 

Hydration is present at the cellular level in the body. Through diffusion tensor imaging, it is known that water is dispersed differently in the white matter of the brain. In normal white matter, which interconnects parts of the brain, water diffuses in an orderly manner in the direction of the tract or neuron (Sfera et al, 2016). However, in damaged white matter as seen in some dementias, water diffusion is less directional and more chaotic (Filley, 2005).

 

We know water is crucial to the normal and optimized functioning of the brain and that it acts differently in damaged brain matter. An insufficient amount of water would exponentially affect this process and compound issues for those with dementia. It has been found that water is not just a conduit for plaque removal: it is essential to the process itself. Water may even be a critical factor in the destruction of beta amyloid plaques, a known factor in Alzheimer’s disease (Sfera et al, 2016). Research also indicates water is crucial to regulation of insulin in the brain with some early studies linking dementia and diabetes (Morris and Burns, 2012). To compound these issues, the elderly do not have the same sensation of thirst, which decreases with aging. In fact, dehydration acts as a natural anesthetic (Fainsinger & Bruera, 1997 in ANNC, 2016). It stands to reason that if the dementia client feels better if fluids are decreased and is not thirsty, why should they ingest more liquids?

 

Loss of mobility and incontinence may aggravate the dehydration situation. If I am less mobile, I do not want to make frequent trips to the bathroom due to the likelihood of falling. Incontinence can aggravate the situation. Many individuals with incontinence surmise “If I drink more fluids, I am going to be wet; if I am wet, I am going to be cold”.  Frequent changes can help prevent this. Patterning and routine toileting at the same times each day may also help make trips to the bathroom become predictable events.

 

Another factor related to lack of hydration is urinary tract infections. A urinary tract infection, or UTI, occurs when germs enter the urethra and travel into the bladder and kidneys. The elderly are more susceptible to UTIs for several reasons, including weakened immune systems, bladder muscles, and pelvic floor. Symptoms and signs of UTI in the elderly are atypical. A young adult may experience pain, burning, frequency, a change in color or strength of urine, low grade fever, night sweats or chills or a sensation of pressure in the lower pelvic areas. Older adults may develop confusion, delirium, agitation, hallucinations, loss of coordination, falling, dizziness, and unusual changes in behavior including withdrawal (Sollitto, 2017). The Alzheimer’s Society states these behavioral changes, including delirium, can develop in as little as one or two days.  To reduce the risk of UTIs, discuss the issue with your physician, encourage adequate fluid intake, drink cranberry juice or take cranberry tablets if there are no contraindications with other medications or conditions, limit caffeine and alcohol since these irritate the bladder, and change underwear/incontinence protection at least twice a day.

 

Hydration can also be a factor in the incidence of syncope. According to MedicineNet, syncope is a

“Partial or complete loss of consciousness with interruption of awareness of oneself and one's surroundings. When the loss of consciousness is temporary and there is spontaneous recovery, it is referred to as syncope or, in nonmedical quarters, fainting.”(syncope. 2017. In MedicineNet.com. Retrieved May 14, 2018 from https://www.medicinenet.com).

Although syncope may sometimes mimic a seizure, it is a transient versus prolonged loss of consciousness where mental function is quickly recovered. In a seizure, by contrast, residual confusion may last minutes or hours (Arthur and Kaye, 2001). According to Arthur and Kaye (2001), there are three kinds of syncope, differentiated by the causes of an episode. The first is neurally mediated syncope. This type of syncope can be caused by neck turning, stress, pain, fear, crowding, prolonged upright posture, cough, swallowing, or a bowel movement, and may have multiple occurrences. These syncope incidences may have premonitory symptoms such as headache, light-headedness, nausea, yawning, and weakness. The second type of syncope is cardiac. This type includes issues with the carotid arteries and can be induced by illicit drug use, some medications, or by exertion or effort. The patient may experience palpitations, and/or chest pain. These episodes are unrelated to posture and may even occur while shaving or from a tight collar. The third is orthostatic syncope. This type of syncope can occur after abrupt changes in posture and can be caused by medication, diuretics, alcohol, and dehydration. One frequent catalyst is a change in medication dosage or initiation of a new medication. Blood pressure medications, nitrates, and diuretics frequently contribute to incidences of syncope. This is confirmed by an abrupt drop in systolic BP upon standing. It should be noted that Arthur and Kaye (2001) indicate an abnormal ECG is found in 50% of patients with syncope but these results are usually not diagnostic.

 

Fluid intake is critical for normal body function. Although it might be difficult to convince your loved one to drink or consume foods with high water content, it is absolutely essential. According to Popkin et al and his colleagues (2010), there is no consensus regarding the recommended quantity of water consumption because of the extreme variation in individual metabolism, physical size, gender, activity level, and existing environmental conditions. It is generally thought that more water is best. Clinical signs of dehydration include dry oral mucous membranes, tongue furrows and/or dryness, decreased saliva, sunken eyes, decreased urine output, upper body weakness, and rapid pulse (Vivanti et al, 2010).

 

As with many care issues in dementia, it is better to offer instead of asking if the patient would like a sip or beverage. According to the ANNC (2011), “Older adults may benefit from drinking according to a schedule rather than waiting until they feel thirsty, since their thirst perception may be blunted”. Offer choices of fluids and place them both in front of the dementia client in their line of eyesight to account for peripheral vision changes. If one beverage is refused when offered, try offering the other beverage. Keep fluids at a temperature other than lukewarm. Cold and warm liquids are more easily consumed as tepid temperatures do not generate a sensation to swallow. Straws are also useful in hydration. More can be held in the mouth prior to swallowing and the client does not necessarily have to touch the cold glass or cup. A cushioned koozie can be used to allow an easier time grasping the cup and provides insulation between hand and cup when this is a deterrent to drinking.

 

One final note for this section: Much of our water consumption is through food. Popkin et al (2010) published a table showing the water content range for common foods. It is from the USDA National Nutrient Database for Standard Reference (Release 21 provided in Altman, 1961.)

Even foods such as butter and margarine contain between 10-19% water, pizza 40-49%, and shrimp 70-79%!  Bottom line: Encourage your IWD to drink and eat up!!

​

The Water Content Range for Selected Foods

Percentage Food Item

100% Water

90–99% Fat-free milk, cantaloupe, strawberries, watermelon, lettuce, cabbage, celery, spinach, pickles, squash (cooked)

80–89% Fruit juice, yogurt, apples, grapes, oranges, carrots, broccoli (cooked), pears, pineapple

70–79% Bananas, avocados, cottage cheese, ricotta cheese, potato (baked), corn (cooked), shrimp

60–69% Pasta, legumes, salmon, ice cream, chicken breast

50–59% Ground beef, hot dogs, feta cheese, tenderloin steak (cooked)

40–49% Pizza

30–39% Cheddar cheese, bagels, bread

20–29% Pepperoni sausage, cake, biscuits

10–19% Butter, margarine, raisins

1–9% Walnuts, peanuts (dry roasted), chocolate chip cookies, crackers, cereals, pretzels, taco shells, peanut butter

0% Oils, sugars

Source: The USDA National Nutrient Database for Standard Reference, Release 21 provided in Altman.127 (in Popkin et al, 2010, page 25)

(Altman P. Blood and Other Body Fluids. Washington DC: Federation of American Societies for Experimental Biology; 1961).

 

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