Hydration Management

Maintaining adequate fluid balance is an essential component of health across the life span; older adults are more vulnerable to shifts in water balance, both overhydration and dehydration, because of age-related changes and increased likelihood that an older individual has several medical conditions. Underhydration and dehydration are the more frequently occurring problem.

BACKGROUND AND STATEMENT OF THE PROBLEM

A.  Definitions

  1. Dehydration is depletion in TBW content caused by pathological fluid losses, diminished water intake, or a combination of both. It results in hypernatremia (more than 145 mEq/L) in the extracellular fluid compartment, which draws water from the intracellular fluids (Metheny, 2000). The water loss is shared by all body-fluid compartments, and relatively little reduction in extracellular fluids occurs. Thus, circulation is not compromised unless the loss is very large.
  2. Underhydration is a precursory condition to dehydration associated with insidious onset and poor outcomes (Mentes & Culp, 2003). Others have referred to this condition as mild dehydration (Stookey, 2005; Stookey et al., 2005), chronic dehydration (Bennett et al., 2004), or impending water-loss dehydration (Hooper et al., 2011).

Etiological factors associated with dehydration

Environment: Residing in long-term care as compared with community dwelling (Lesnik et al., 2017; Rodrigues et al., 2015)

 

Staff and family characteristics

Inadequate staff and professional supervision: Kayser-Jones, Schell, Porter, Barbaccia, & Shaw, 1999

Presence of more staff: Namasivayam-MacDonald et al., 2018

Family or caregivers not spending time with patient: Mentes, Chang, & Morris, 2006

 

Age-related risk factors

Age-related changes in body composition with resulting decrease in TBW: Bossingham et al., 2005; Lavizzo-Mourey et al., 1988; Metheny, 2000

Decreasing renal function: Lindeman, Tobin, & Shock, 1985

Lack of thirst: Farrell et al., 2008; Kenney & Chiu, 2001; Mack et al., 1994; Miescher & Fortney, 1989; Phillips et al., 1984; Phillips et al., 1991

Poor tolerance for hot weather: Josseran et al., 2009

 

Risk factors: Individual characteristics

Older than 85 years of age: Ciccone et al., 1998; Gaspar, 1999; Goldberg et al., 2014: Lavizzo-Mourey et al., 1988; Mentes et al., 2019; Murray et al., 2015

Female: Gaspar, 1988; Lavizzo-Mourey et al., 1988; Marra et al., 2016; Namasivayam-MacDonald et al., 2018

Semidependent in eating: Gaspar, 1999; Gaspar et al., 2019

Functionally more independent: Gaspar, 1999; Mentes & Culp, 2003

Functionally more dependent (especially with eating): Botigué et al., 2018; Marra et al., 2016; Mentes et al., 2019; Murray et al., 2015; Namasivayam-MacDonald et al., 2018

Few fluid ingestion opportunities: Gaspar, 1988, 1999; O. F. Jimoh, Brown, Bunn, & Hooper, 2019

Inadequate nutrient intake: Gaspar, 1999; McGrail & Kelchner, 2015

Alzheimer’s disease or other dementias or cognitive impairment: Albert, Nakra, Grossberg, & Caminal, 1989, 1994; Botigué et al., 2018; Marra et al., 2016; McGrail & Kelchner, 2015; Namasivayam-MacDonald et al., 2018; Paulis et al., 2018

Four or more chronic conditions: Lavizzo-Mourey et al., 1988

Four medications: Lavizzo-Mourey et al., 1988

Fever: Pals et al., 1995; Paulis et al., 2018; Weinberg et al., 1994

Vomiting and diarrhea: Wakefield, Mentes, Holman, & Culp, 2008

Individuals with infections: Warren et al., 1994

Individuals who have had prior episodes of dehydration: Mentes, 2006

Depression or loneliness associated with decreased fluid intake as identified by nursing staff: Mentes, Chang, & Morris, 2006

Diuretics: thiazide: Wakefield et al., 2008

Diuretics: loop and thiazide: Lancaster et al., 2003

Risk of pressure ulcer: Botigué et al., 2018

Texture modified diet: Botigué et al., 2018; Painter, Le Couteur, & Waite, 2017

Receiving oral nutritional supplement: Marra et al., 2016

Impaired swallowing and/or dysphagia: Botigué et al., 2018

Diabetes: Marra et al., 2016

 

Interventions for Enhancing Hydration Status

A. Risk identification

Mentes & IVANRC, 2000

  1. Identify acute situations: vomiting, diarrhea, or febrile episodes: Mentes & IVANRC, 2000
  2. Use a tool to evaluate risk: Mentes & IVANRC, 2000
    • Dehydration Risk Appraisal Checklist (LTC): Mentes & Wang, 2010
    • Northumbria Assessment of Hydration (acute care) Risk of insufficient fluid intake: Oates et al., 2017
  3. Use a tool to evaluate adequacy of intake: Drink Diary: O. Jimoh, Bunn, & Hooper, 2015

B. Acute hydration management

Monitor input and output: Weinberg et al., 1994

Provide additional fluids as tolerated: Weinberg et al., 1994

Minimize fasting times for diagnostic and surgical procedures: Parameters, 2017

Offer subcutaneous or intravenous fluid in parallel with encouraging oral fluid intake for those experiencing dehydration and who are unable to drink: Volkert et al., 2018

C. Chronic/long-term hydration management

Systematic reviews of evidence have not identified a specific intervention for the management of dehydration and/or inadequate fluid intake (Abdelhamid et al., 2016; Bunn et al., 2016; Herke et al., 2018; Volkert et al., 2018). An individualized resident-centered care plan that considers the following strategies is needed (Volkert et al., 2018)

Provide fluids consistently throughout the day

Bak, Wilson, Tsiami, & Loveday, 2018; Bunn, Jimoh, Wilsher, & Hooper, 2015; Ferry, 2005; Hodgkinson et al., 2003; F. O. Jimoh et al., 2015; O. F. Jimoh et al., 2019; Mentes, Chang, & Morris, 2006; Oates & Price, 2017; Robinson & Rosher, 2002; Simmons, Alessi, & Schnelle, 2001; Volkert et al., 2018

Specific Effective Strategies

Plan fluid intake as follows: 75%–80% delivered at meals, and 20%–25% delivered during nonmeal times such as medication times and planned nourishment times: Volkert et al., 2018

Offer a variety of fluids keeping in mind the individual’s previous intake pattern: Bunn et al., 2015; Godfrey, Cloete, Dymond, & Long, 2012; Schnelle et al., 2010; Simmons et al., 2001; Volkert et al., 2018; Wilson et al., 2019: Zembrzuski, 1997

Integrate fluid rounds midmorning and late afternoon, where caregiver provides additional fluids: Spangler, Risley, & Bilyew, 1984

Standardize fluid with medication administrations to a prescribed amount; e.g. 180 mL (6 oz.) per administration time: O. F. Jimoh et al., 2019; Mentes & Culp, 2003

Provide 2–8 oz. glasses of fluid in a.m. and p.m: Robinson & Rosher, 2002

If taking thickened liquids, encourage intake (water intake lower when taking thickened liquids as compared with thin liquids): McGrail & Kelchner, 2012, 2015; Painter et al., 2017

Select between-meal snacks that will increase water intake: Marra et al., 2016

Provide fluids between waking and breakfast: O. F. Jimoh et al., 2019

Provide reminders/prompts to drink fluids: Bak et al., 2018; Bunn et al., 2015; Godfrey et al., 2012; Oates & Price, 2017

Offer a variety of fluids with consideration for residents’ preference: Godfrey et al., 2012; Mentes, Chang, & Morris, 2006; Robinson & Rosher, 2002; Schnelle et al., 2010; Simmons et al., 2001; Wilson et al., 2019

Interventions and Strategies

References

Make drinking opportunity a pleasurable and social experience

Abdelhamid et al., 2016; Cook, Hodgson, Hope, Thompson, & Shaw, 2019; Godfrey et al., 2012

Specific Effective Strategies

“Happy Hours” in the afternoon, where residents can gather together for additional fluids and socialization: Mentes, Chang, & Morris, 2006; Musson et al., 1990

“Tea Time” in the afternoon, where residents come together for fluids, nourishment, and socialization: Mueller & Boisen, 1989

Encourage resident to have meals in the dining room: Reed, Zimmerman, Sloane, Williams, & Boustani, 2005; Volkert et al., 2018

Create a noninstitutional dining experience: Reed et al., 2005, Volkert et al., 2018

Create a drink-friendly environment: Cook et al., 2019

Ensure utensils and level of assistance are resident centered

Specific Effective Strategies

Use of modified fluid containers based on resident’s intake behaviors (e.g., ability to hold cup, to swallow): Bak et al., 2018; Mueller & Boisen, 1989; Reedy, 1988

Use high-contrast tableware during meals for residents with dementia: Dunne, Neargarder, Cipolloni, & Cronin-Golomb, 2004

Provide the appropriate level of assistance to enhance intake: Bunn et al., 2015; Godfrey et al., 2012; Marra et al., 2016

Increase toileting routine (in combination with other strategies): Bunn et al., 2015; Schnelle et al., 2010; Spangler et al., 1984; Tanaka et al., 2009; Zembrzuski, 2006

Interventions and Strategies

References

Ensure care providers (formal and informal) are knowledgeable of hydration needs and management strategies

Specific Effective Strategies

Bunn et al., 2015

Provide staff with education on hydration management (in combination with other strategies): Beattie, O’Reilly, Strange, Franklin, & Isenring, 2014; Greene et al., 2018; Oates & Price, 2017; Volkert et al., 2018; Zembrzuski, 2006

Coordinate staff communication about hydration such as certified nursing assistant (CNA) handoff reports or documentation in nursing care plan.: Mentes, Chang, & Morris, 2006; Ullrich & McCutcheon, 2008

Provide a staffing ratio that allows the needs of the residents to be met: Namasivayam-MacDonald et al., 2018; Reed et al., 2005

Encourage family involvement and support

Mentes, Chang, & Morris, 2006

Promote Self-Management of Hydration

Provide education to improve individuals’ hydration health literacy: Picetti et al., 2017

Individuals who are cognitively intact and physically capable can be taught to use the Drinks Diary to self-monitor their fluid intake.: Jimoh et al., 2015

Assist to establish individuals' fluid intake goal based on the calculated fluid recommendation.: Volkert et al., 2018

Individuals who are cognitively intact and visually capable can be taught how to note changes in their level of hydration through the use of a color chart, to compare with the color of their urine. The chart is most accurate in individuals with better renal function.: Armstrong et al., 1994, 1998; Mentes, Wakefield, & Culp, 2006

Fluid Regulation and Documentation

Note: Frequency of documentation of fluid intake will vary from setting to setting and is dependent on an individual’s condition.

Document a complete intake recording, including hydration habits: Mentes & IVANRC, 2000

Create fluid volume list of each utensil to accurately calculate fluid consumption: Burns, 1992; Hart & Adamek, 1984

Implement use of the Drinks Diary: F. O. Jimoh et al., 2015

PARAMETERS OF ASSESSMENT

A. Health history

Mentes & IVANRC, 2000

Specific disease states: dementia, congestive heart failure, chronic renal disease, malnutrition, and psychiatric disorders such as depression: Albert et al., 1989; Gaspar, 1988; Warren et al., 1994

Presence of comorbidities: more than four chronic health conditions: Lavizzo-Mourey et al., 1988

Prescription drugs: number and types: Lavizzo-Mourey et al., 1988

Past history of dehydration, repeated infections: Mentes, 2006

B. Physical assessments

Complete an exam that includes vital signs, height, weight, BMI (Vivanti et al., 2008), review of systems, Mentes & IVANRC, 2000

C. Focused assessment on indicators of hydration

Chief complaint of fatigue: Hooper et al., 2015

D. Laboratory tests (Mentes & Gaspar, 2020)

Urine specific gravity: Mentes, 2006; Wakefield et al., 2002

Urine color: Mentes, 2006; Wakefield et al., 2002

BUN–creatinine ratio: Mentes & Gaspar, 2020

Serum sodium: Mentes & Gaspar, 2020

Serum osmolality and a serum osmolality estimation equation based on serum measures of urea, glucose, sodium, and potassium: Siervo, Bunn, Prado, & Hooper, 2014

Salivary osmolality: Fortes et al., 2015

E. Assessment of ingestion behaviors and hydration habits

Individual fluid-intake behaviors: Mentes, 2006

Subcategory of hydration patterns (can drink, cannot drink, will not drink, end of life): Mentes, 2006

Missing drinks between meals: Hooper et al., 2015

Screen hospitalized older adults using the NoAH: Oates et al., 2017

 

EVALUATION AND EXPECTED OUTCOMES

A.  Maintenance of body hydration (Mentes & Culp, 2003; Robinson & Rosher, 2002; Simmons et al., 2001)

B.  Decreased infections, especially urinary tract infections (McConnell, 1984; Mentes & Culp, 2003; Robinson & Rosher, 2002; Murry et al., 2015)

C.  Improvement in urinary incontinence (Spangler et al., 1984)

D.  Lowered urinary pH (Hart & Adamek, 1984)

E.  Decreased constipation (Murray et al., 2015; Robinson & Rosher, 2002)

F.   Decreased acute confusion (Mentes et al., 1999)

G.  Improved fluid intake

H.  Improved hydration health literacy (Picetti et al., 2017)

 

FOLLOW-UP MONITORING OF CONDITION

A.  Urine color chart monitoring in patients with better renal function (Armstrong et al., 1994, 1998; Wakefield et al., 2002)

B.  Urine specific gravity checks (Armstrong et al., 1994, 1998; Wakefield et al., 2002)

C.  Twenty-four-hour intake recording (Metheny, 2000)

D.  Drinks Diary to document fluid intake in individuals who are cognitively intact (F. O. Jimoh et al., 2015)

E.  Hydration Health literacy (Picetti et al., 2017)

F.   Salivary Osmolality (Volkert et al., 2018)

 

RELEVANT PRACTICE GUIDELINES

A.  Hydration management evidence-based protocol available from the University of Iowa College of Nursing Gerontological Nursing Interventions Research Center, Research Dissemination Core. Authors: Janet Mentes and Phyllis Gaspar, revised 2019.

B.  ESPEN (European Society for Clinical Nutrition and Metabolism) guideline on clinical nutrition and hydration in geriatrics (Volkert et al., 2018).

C.  Dehydration and Fluid Maintenance in the Long-Term Care Setting Clinical Practice Guideline by The American Medical Directors Association, 2009.

 

ABBREVIATIONS

BMI             Body mass index

BUN            Blood urea nitrogen

IVANRC    Iowa–Veterans Affairs Nursing Research Consortium

MMSE         Mini-Mental State Examination

NoAH         Northumbria Assessment of Hydration

TBW            Total body water

----

Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

REFERENCES

Abdelhamid, A., Bunn, D., Copley, M., Cowap, V., Dickinson, A., Gray, L., … Hooper, L. (2016). Effectiveness of interventions to directly support food and drink intake in people with dementia: Systematic review and meta-analysis. BMC Geriatrics, 16(1). doi:10.1186/s12877-016-0196-3. Evidence Level I.

Albert, S. G., Nakra, B. R., Grossberg, G. T., & Caminal, E. R. (1989). Vasopressin response to dehydration in Alzheimer’s disease. Journal of the American Geriatrics Society, 37(9), 843–847. doi:10.1111/j.1532-5415.1989.tb02264.x. Evidence Level III.

Albert, S. G., Nakra, B. R., Grossberg, G. T., & Caminal, E. R. (1994). Drinking behavior and vasopressin responses to hyperosmolality in Alzheimer’s disease. International Psychogeriatrics, 6(1), 79–86. doi:10.1017/S104161029400164X. Evidence Level III.

Armstrong, L. E., Maresh, C. M., Castellani, J. W., Bergeron, M. F., Kenefick, R. W., LaGasse, K. E., & Riebe, D. (1994). Urinary indices of hydration status. International Journal of Sport Nutrition, 4(3), 265–279. doi:10.1123/ijsn.4.3.265. Evidence Level IV.

Armstrong, L. E., Soto, J. A., Hacker, F. T., Jr., Casa, D. J., Kavouras, S. A., & Maresh, C. M. (1998). Urinary indices during dehydration, exercise, and rehydration. International Journal of Sport Nutrition, 8(4), 345–355. doi:10.1123/ijsn.8.4.345. Evidence Level IV.

Bak, A., Wilson, J., Tsiami, A., & Loveday, H. (2018). Drinking vessel preferences in older nursing home residents: Optimal design and potential for increasing fluid intake. British Journal of Nursing, 27(22), 1298–1304. doi:10.12968/bjon.2018.27.22.1298. Evidence Level V.

Beattie, E., O’Reilly, M., Strange, E., Franklin, S., & Isenring, E. (2014). How much do residential aged care staff members know about the nutritional needs of residents? International Journal of Older People Nursing, 9(1), 54–64. doi:10.1111/opn.1216. Evidence Level IV.

Bennett, J. A., Thomas, V., & Riegel, B. (2004). Unrecognized chronic dehydration in older adults: Examining prevalence rate and risk factors. Journal of Gerontological Nursing, 30(11), 22–28; quiz 52–23. doi:10.3928/0098-9134-20041101-09. Evidence Level IV.

Bossingham, M. J., Carnell, N. S., & Campbell, W. W. (2005). Water balance, hydration status, and fat-free mass hydration in younger and older adults. American Journal of Clinical Nutrition, 81(6), 1342–1350. doi:10.1093/ajcn/81.6.1342. Evidence Level II.

Botigué, T., Masot, O., Miranda, J., Nuin, C., Viladrosa, M., Lavedán, A., & Zwakhalen, S. (2018). Prevalence and risk factors associated with low fluid intake in institutionalized older residents. Journal of the American Medical Directors Association, 20(3), 317–322. doi:10.1016/j.jamda.2018.08.011. Evidence Level IV.

Bunn, D. K., Abdelhamid, A., Copley, M., Cowap, V., -Dickinson, A., Howe, A., … Hooper, L. (2016). Effectiveness of interventions to indirectly support food and drink intake in people with dementia: Eating and Drinking Well in dementiA (EDWINA) systematic review. BMC Geriatrics, 16(1). doi:10.1186/s12877-016-0256-8. Evidence Level I.

Bunn, D. K., Jimoh, F., Wilsher, S. H., & Hooper, L. (2015). Increasing fluid intake and reducing dehydration risk in older people living in long-term care: A systematic review. Journal of the American Medical Directors Association, 16, 101–113. doi:10.1016/j.jamda.2014.10.016. Evidence Level I.

Burns, D. (1992). Working up a thirst. Nursing Times, 88(26), 44–45. Evidence Level IV.

Ciccone, A., Allegra, J. R., Cochrane, D. G., Cody, R. P., & Roche, L. M. (1998). Age-related differences in diagnoses within the elderly population. American Journal of Emergency Medicine, 16(1), 43–48. doi:10.1016/s0735-6757(98)90063-8. Evidence Level IV.

Cook, G., Hodgson, P., Hope, C., Thompson, J., & Shaw, L. (2019). Hydration practices in residential and nursing care homes for older people. Journal of Clinical Nursing, 28, 1201–1215. doi:10.1111/jocn.14727. Evidence Level IV.

Dunne, T., Neargarder, S., Cipolloni, P., & Cronin-Golomb, A. (2004). Visual contrast enhances food and liquid intake in advanced Alzheimer’s disease. Clinical Nutrition, 23(4), 533–538. doi:10.1016/j.clnu.2003.09.015. Evidence Level IV.

Farrell, M. J., Zamarripa, F., Shade, R., Phillips, P. A., McKinley, M., Fox, P. T., … Egan, G. F. (2008). Effect of aging on regional cerebral blood flow responses associated with osmotic thirst and its satiation by water drinking: A PET study. Proceedings of the National Academy of Sciences of the United States of America, 105(1), 382–387. doi:10.1073/pnas.0710572105. Evidence Level III.

Ferry, M. (2005). Strategies for ensuring good hydration in the elderly. Nutrition Reviews, 63(6 Pt. 2), S22–S29. doi:10.1111/j.1753-4887.2005.tb00151.x. Evidence Level VI.

Fortes, M. B., Owen, J. A., Raymond-Barker, P., Bishop, C., Elghenzai, S., Oliver, S. J., & Walsh, N. P. (2015). Is this elderly patient dehydrated? Diagnostic accuracy of hydration assessment using physical signs, urine and saliva markers. Journal of American Medical Directors Association, 16, 221–228. doi:10.1016/j.jamda.2014.09.012. Evidence Level IV.

Gaspar, P. M. (1988). What determines how much patients drink? Geriatric Nursing, 9(4), 221–224. doi:10.1016/s0197-4572(88)80145-9. Evidence Level IV.

Gaspar, P. M. (1999). Water intake of nursing home residents. Journal of Gerontological Nursing, 25(4), 23–29. doi:10.3928/0098-9134-19990401-06. Evidence Level IV.

Gaspar, P. M., Scherb, C., & Rivera-Mariani, F. (2019). Hydration status of assisted living memory care residents. Journal of Gerontological Nursing, 45(4), 21–29. doi:10.3928/00989134-20190213-02. Evidence Level IV.

Godfrey, H., Cloete, J., Dymond, E., & Long, A. (2012). An exploration of the hydration care of older people: A qualitative study. International Journal of Nursing Studies, 49(10), 1200–1211. doi:10.1016/j.ijnurstu.2012.04.009. Evidence Level IV.

Goldberg, L., Heiss, C. J., Parson, S., Foley, A. S., Mefferd, A., -Hollinger, D., … Patterson, J. (2014). Hydration in older adults: The contribution of bioelectrical impedance analysis. International Journal of Speech Language Pathology, 16(3), 273–281. doi:10.3109/17549507.2014.882989. Evidence Level IV.

Greene, C., Canning, D., Wilson, J., Bak, A., Tingle, A., Tsiami, A., & Loveday, H. (2018). I-Hydrate training intervention for staff working in a care home setting: An observational study. Nurse Education Today, 68, 61–65. doi:10.1016/j.nedt.2018.05.014. Evidence Level V.

Hart, M., & Adamek, C. (1984). Do increased fluids decrease urinary stone formation? Geriatric Nursing, 5(6), 245–248. Evidence Level III.

Herke, M., Fink, A., Langer, G., Wustmann, T., Watzke, S., Hanff, A. M., & Burckhardt, M. (2018). Environmental and behavioural modifications for improving food and fluid intake in people with dementia. Cochrane Database of Systematic Reviews, 2018(7), CD011542. doi:10.1002/14651858.CD011542.pub2. Evidence Level I.

Hodgkinson, B., Evans, D., & Wood, J. (2003). Maintaining oral hydration in older adults: A systematic review. International Journal of Nursing Practices, 9(3), S19–S28. doi:10.1046/j.1440-172X.2003.00425.x. Evidence Level I.

Hooper, L., Attreed, N. J., Campbell, W. W., Channell, A. M., Chassagne, P., Culp, K., … Hunter, P. (2011). Clinical and physical signs for identification of impending and current water-loss dehydration in older people [Protocol]. Cochrane Database of Systematic Reviews, 2011(2), CD009647. doi:10.1002/14651858.CD009647. Evidence Level I.

Hooper, L., Attreed, N. J., Campbell, W. W., Channell, A. M., Chassagne, P., Culp, K. R., … Hunter, P. (2015). Clinical symptoms, signs and tests for identification of impending and current water loss dehydration in older adults (1007). Cochrane Database of Systematic Reviews, 4, CD009647. doi:10.1002/14651858CD009647.Pub2. Evidence Level I.

Jimoh, F. O., Bunn, D., & Hooper, L. (2015). Assessment of a self-reported Drinks Diary for the estimation of drinks intake by care home residents: Fluid intake study in the elderly (FISE). Journal of Nutrition, Health and Aging, 19(5), 491–496. doi:10.1007/s12603-015-0458-3. Evidence Level IV.

Jimoh, O. F., Brown, T., Bunn, D., & Hooper, L. (2019). Beverage intake and drinking patterns: Clues to support older people living in long-term care to drink well: DRIE and FISE studies. Nutrients, 11(2), 447. doi:10.3390/nu11020447. Evidence Level IV.

Josseran, L., Caillère, N., Brun-Ney, D., Rottner, J., Filleul, L., Brucker, G., & Astagneau, P. (2009). Syndromic surveillance and heat wave morbidity: A pilot study based on emergency departments in France. BMC Medical Informatics and Decision Making, 9, 14. doi:10.1186/1472-6947-9-14. Evidence Level IV.

Kayser-Jones, J., Schell, E. S., Porter, C., Barbaccia, J. C., & Shaw, H. (1999). Factors contributing to dehydration in nursing homes: Inadequate staffing and lack of professional supervision. Journal of the American Geriatrics Society, 47(10), 1187–1194. doi:10.1111/j.1532-5415.1999.tb05198.x. Evidence Level IV.

Kenney, W. L., & Chiu, P. (2001). Influence of age on thirst and fluid intake. Medicine and Science in Sports and Exercise, 33(9), 1524–1532. doi:10.1097/00005768-200109000-00016. Evidence Level V.

Lancaster, K. J., Smiciklas-Wright, H., Heller, D. A., Ahern, F. M., & Jensen, G. (2003). Dehydration in Black and White older adults using diuretics. Annals of Epidemiology, 13(7), 525–529. doi:10.1016/S1047-2797(03)00004-8. Evidence Level IV.

Lavizzo-Mourey, R., Johnson, J., & Stolley, P. (1988). Risk factors for dehydration among elderly nursing home residents. Journal of the American Geriatrics Society, 36(3), 213–218. doi:10.1111/j.1532-5415.1988.tb01803.x. Evidence Level IV.

Lesnik, A., Piko, N., Zeleznik, D., & Bevc, S. (2017). Dehydration of older patients in institutional care and the home environment. Research in Gerontological Nursing, 10(6), 260–266. doi:10.3928/19404921-20171013-03. Evidence Level IV.

Lindeman, R. D., Tobin, J., & Shock, N. W. (1985). Longitudinal studies on the rate of decline in renal function with age. Journal of the American Geriatrics Society, 33(4), 278–285. doi:10.1111/j.1532-5415.1985.tb07117.x. Evidence Level IV.

Mack, G. W., Weseman, C. A., Langhans, G. W., Scherzer, H., -Gillen, C. M., & Nadel, E. R. (1994). Body fluid balance in dehydrated healthy older men: Thirst and renal osmoregulation. Journal of Applied Physiology, 76(4), 1615–1623. doi:10.1152/jappl.1994.76.4.1615. Evidence Level III.

Marra, M., Simmons, S., Shotwell, M., Hudson, A., Hollingsworth, E., Long, E., … Silver, H. (2016). Elevated serum osmolality and total water deficit indicate impaired hydration status in residents of long-term care facilities regardless of low or high body mass index. Journal of the Academy of Nutrition and Dietetics, 116(5), 828–836.e822. doi:10.1016/j.jand.2015.12.011. Evidence Level IV.

McConnell, J. (1984). Preventing urinary tract infections. Geriatric Nursing, 5(8), 361–362. doi:10.1016/s0197-4572(84)80007-5. Evidence Level III.

McGrail, A., & Kelchner, L. (2012). Adequate oral fluid intake in hospitalized stroke patients: Does viscosity matter? Rehabilitation Nursing, 37(5), 252–257. doi:10.1002/rnj.23. Evidence Level IV.

McGrail, A, & Kelchner, L. (2015). Barriers to oral fluid intake: Beyond thickened liquids. Journal of Neuroscience Nursing, 47(1), 58–63. doi:10.1097/JNN.0000000000000114. Evidence Level IV.

Mentes, J. C. (2006). A typology of oral hydration problems exhibited by frail nursing home residents. Journal of Gerontological Nursing, 32(1), 13–19, quiz 20–21. doi:10.3928/0098-9134-20060101-09. Evidence Level IV.

Mentes, J. C., Chang, B. L., & Morris, J. (2006). Keeping nursing home residents hydrated. Western Journal of Nursing Research, 28(4), 392–406; discussion 407–418. doi:10.1177/0193945906286607. Evidence Level IV.

Mentes, J. C., & Culp, K. (2003). Reducing hydration-linked events in nursing home residents. Clinical Nursing Research, 12(3), 210–225; discussion 226–228. doi:10.1177/1054773803252996. Evidence Level III.

Mentes, J. C., Culp, K., Maas, M., & Rantz, M. (1999). Acute confusion indicators: Risk factors and prevalence using MDS data. Research in Nursing & Health, 22(2), 95–105. doi:10.1002/(SICI)1098-240X(199904)22:2<95::AID-NUR2>3.0.CO;2-R. Evidence Level IV.

Mentes, J. C., DeVost, M. A., & Nandy, K. (2019). Salivary osmolality, function, and hydration habits in community-dwelling older adults. SAGE Open Nursing, 5, 237796081982625. doi:10.1177/2377960819826253. Evidence Level IV.

Mentes, J. C., & Gaspar, P. M. (2020). Evidence-based protocol: Hydration management. In Series on evidence-based practice for older adults. Iowa City: University of Iowa College of Nursing, Csomay Center for Gerontological Excellence. Evidence Level I.

Mentes, J. C., & Iowa–Veterans Affairs Research Consortium. (2000). Hydration management protocol. Journal of Gerontological Nursing, 26(10), 6–15. doi:10.3928/0098-9134-20001001-04. Evidence Level I.

Mentes, J. C., Wakefield, B., & Culp, K. (2006). Use of a urine color chart to monitor hydration status in nursing home residents. Biological Research for Nursing, 7(3), 197–203. doi:10.1177/1099800405281607. Evidence Level IV.

Mentes, J. C., & Wang, J. (2010). Measuring risk for dehydration in nursing home residents. Research in Gerontological Nursing, 31, 1–9. doi:10.1177/1099800405281607. Evidence Level IV.

Metheny, N. (2000). Fluid and electrolyte balance: Nursing considerations (4th ed.). St. Louis, MO: Lippincott Williams & Wilkins. Evidence Level VI.

Miescher, E., & Fortney, S. M. (1989). Responses to dehydration and rehydration during heat exposure in young and older men. American Journal of Physiology, 257(5 Pt. 2), R1050–1056. doi:10.1152/ajpregu.1989.257.5.R1050. Evidence Level III.

Mueller, K. D., & Boisen, A. M. (1989). Keeping your patient’s water level up. RN, 52(7), 65–68. Evidence Level V.

Murray, J., Doeltgen, S., Miller, M., & Scholten, I. (2015). A descriptive study of the fluid intake, hydration, and health status of rehabilitation inpatients without dysphagia following stroke. Journal of Nutrition in Gerontology and Geriatrics, 34(3), 292–304. doi:10.1080/21551197.2015.1054573. Evidence Level IV.

Musson, N. D., Kincaid, J., Ryan, P., Glussman, B., Varone, L., Gamarra, N., … Silverman, M. (1990). Nature, nurture, nutrition: Interdisciplinary programs to address the prevention of malnutrition and dehydration. Dysphagia, 5(2), 96–101. doi:10.1007/BF02412651. Evidence Level V.

Namasivayam-MacDonald, A. M., Slaughter, S. E., Morrison, J., Steele, C. M., Carrier, N., Lengyel, C., & Keller, H. H. (2018). Inadequate fluid intake in long term care residents: Prevalence and determinants. Geriatric Nursing, 39(3), 330–335. doi:10.1016/j.gerinurse.2017.11.004. Evidence Level IV.

Oates, L. L., & Price, C. I. (2017). Clinical assessments and care interventions to promote oral hydration amongst older patients: A narrative systematic review. BMC Nursing, 16(1), 3–4. doi:10.1186/s12912-016-0195-x. Evidence Level V.

Oates, L. L., Vicky, R., Plank, J., & Price, C. I. (2017). A protocol for assessing the risk of dehydration in older people. Nursing Times, 113(1), 37–40. Evidence Level V. Retrieved from https://cdn.ps.emap.com/wp-content/uploads/sites/3/2017/01/037-040_A-protocol-for-assessing-the-risk-of-dehydration-in-older-people.pdf

Painter, V., Le Couteur, D. G., & Waite, L. M. (2017). Texture-modified food and fluids in dementia and residential aged care facilities. Clinical Interventions in Aging, 12, 1193–1203. doi:10.2147/CIA.S140581. Evidence Level I.

Pals, J. K., Weinberg, A. D., Beal, L. F., Levesque, P. G., Cunnungham, T. J., & Minaker, K. L. (1995). Clinical triggers for detection of fever and dehydration. Implications for long-term care nursing. Journal of Gerontological Nursing, 21(4), 13–19. doi:10.3928/0098-9134-19950401-04. Evidence Level IV.

Parameters, P. (2017). Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures. Anesthesiology, 126(3), 376–393. doi:10.1097/ALN.0000000000001452. Evidence Level I.

Paulis, S. J. C., Everink, I. H. J., Halfens, R. J. G., Lohrmann, C., & Schols, J. M. G. A. (2018). Prevalence and risk factors of dehydration among nursing home residents: A systematic review. Journal of the American Medical Directors Association, 19(8), 646–657. doi:10.1016/j.jamda.2018.05.009. Evidence Level I.

Phillips, P. A., Bretherton, M., Johnston, C. I., & Gray, L. (1991). Reduced osmotic thirst in healthy elderly men. American Journal of Physiology, 261(1 Pt. 2), R166–R171. doi:10.1152/ajpregu.1991.261.1.R166. Evidence Level III.

Phillips, P. A., Rolls, B. J., Ledingham, J. G., Forsling, M. L., Morton, J. J., Crowe, M. J., & Wollner, L. (1984). Reduced thirst after water deprivation in healthy elderly men. New England Journal of Medicine, 311(12), 753–759. doi:10.1056/NEJM198409203111202. Evidence Level III.

Picetti, D., Foster, S., Pangle, A. K., Schrader, A., George, M., Wei, J. Y., & Azhar, G. (2017). Hydration health literacy in the elderly. Nutrition and Healthy Aging, 4(3), 227–237. doi:10.3233/NHA-170026. Evidence Level IV.

Reed, P., Zimmerman, S., Sloane, P., Williams, C., & Boustani, M. (2005). Characteristics associated with low food and fluid intake in long-term care residents with dementia. Gerontologist, 45 Spec No 1(1), 74–80. doi:10.1093/geront/45.suppl_1.74. Evidence Level IV.

Reedy, D. (1988). How can you prevent dehydration? Geriatric Nursing, 9(4), 224–226. doi:10.1016/s0197-4572(88)80146-0. Evidence Level V.

Robinson, S. B., & Rosher, R. B. (2002). Can a beverage cart help improve hydration? Geriatric Nursing, 23(4), 208–211. doi:10.1067/mgn.2002.126967. Evidence Level IV.

Rodrigues, S., Silva, J., Severo, M., Inácio, C., Padrão, P., Lopes, C., … Moreira, P. (2015). Validation analysis of a geriatric dehydration screening tool in community-dwelling and institutionalized elderly people. International Journal of Environmental Research and Public Health, 12(3), 2700–2717. doi:10.3390/ijerph120302700. Evidence Level VI.

Schnelle, J. F., Leung, F. W., Rao, S. S., Beuscher, L., Keeler, E., Clift, J., & Simmons, S. (2010). A controlled trial of an intervention to improve urinary and fecal incontinence and constipation. Journal of the American Geriatric Society, 58(8), 1504–1511. doi:10.1111/j.1532-5415.2010.02978.x. Evidence Level II.

Siervo, M., Bunn, D., Prado, C. M., & Hooper, L. (2014). Accuracy of prediction equations for serum osmolarity in frail older people with and without diabetes. American Journal of Clinical Nutrition, 100, 867–876. doi:10.3945/ajcn.114.086769. Evidence Level IV.

Simmons, S. F., Alessi, C., & Schnelle, J. F. (2001). An intervention to increase fluid intake in nursing home residents: Prompting and preference compliance. Journal of the American Geriatrics Society, 49(7), 926–933. doi:10.1046/j.1532-5415.2001.49183.x. Evidence Level II.

Spangler, P. F., Risley, T. R., & Bilyew, D. D. (1984). The management of dehydration and incontinence in nonambulatory geriatric patients. Journal of Applied Behavior Analysis, 17(3), 397–401. doi:10.1901/jaba.1984.17-397. Evidence Level III.

Stookey, J. D. (2005). High prevalence of plasma hypertonicity among community-dwelling older adults: Results from NHANES III. Journal of the American Dietetic Association, 105(8), 1231–1239. doi:10.1016/j.jada.2005.05.003. Evidence Level IV.

Stookey, J. D., Pieper, C. F., & Cohen, H. J. (2005). Is the prevalence of dehydration among community-dwelling older adults really low? Informing current debate over the fluid recommendation for adults aged 70+ years. Public Health Nutrition, 8(8), 1275–1285. doi:10.1079/PHN2005829. Evidence Level IV.

Tanaka, Y., Nagata, K., Tanaka, T., Kuwano, K., Endo, H., Otani, T., … Koyama, H. (2009). Can an individualized and comprehensive care strategy improve urinary incontinence among nursing home residents? Archives of Gerontology and Geriatrics, 49(2), 278–283. doi:10.1016/j.archger.2008.10.006. Evidence Level V.

Ullrich, S., & McCutcheon, H. (2008). Nursing practice and oral fluid intake of older people with dementia. Journal of Clinical Nursing, 17, 2910–2919. doi:10.1111/j.1365-2702.2007.02274.x. Evidence Level V.

Vivanti, A., Harvey, K., Ash, S., & Battistutta, D. (2008). Clinical assessment of dehydration in older people admitted to hospital: What are the strongest indicators? Archives of Gerontology and Geriatrics, 47(3), 340–355. doi:10.1016/j.archger.2007.08.016. Evidence Level IV.

Volkert, D., Beck, A. M., Cederholm, T., Cruz-Jentoft, A., Goisser, S., Hooper, L., … Bischoff, S. C. (2018). ESPEN guideline on clinical nutrition and hydration in geriatrics. Clinical Nutrition, 38(1), 10–47. doi:10.1016/j.clnu.2018.05.024. Evidence Level I.

Wakefield, B. J., Mentes, J., Holman, J. E., & Culp, K. (2008). Risk factors and outcomes associated with hospital admission for dehydration. Rehabilitation Nursing, 33(6), 233–241. doi:10.1002/j.2048-7940.2008.tb00234.x. Evidence Level IV.

Wakefield, B., Mentes, J., Diggelmann, L., & Culp, K. (2002). Monitoring hydration status in elderly veterans. Western Journal of Nursing Research, 24(2), 132–142. doi:10.1177/01939450222045798. Evidence Level IV.

Warren, J. L., Bacon, W. E., Harris, T., McBean, A. M., Foley, D. J., & Phillips, C. (1994). The burden and outcomes associated with dehydration among US elderly, 1991. American Journal of Public Health, 84(8), 1265–1269. doi:10.2105/ajph.84.8.1265. Evidence Level IV.

Weinberg, A. D., Pals, J. K., Levesque, P. G., Beal, L. F., Cunningham, T. J., & Minaker, K. L. (1994). Dehydration and death during febrile episodes in the nursing home. Journal of the American Geriatrics Society, 42(9), 968–971. doi:10.1111/j.1532-5415.1994.tb06589.x. Evidence Level IV.

Wilson, J., Bak, A., Tingle, A., Greene, C., Tsiami, A., Canning, D., … Loveday, H. (2019). Improving hydration of care home residents by increasing choice and opportunity to drink: A quality improvement study. Clinical Nutrition, 38(4), 1820–1827. doi:10.1016/j.clnu.2018.07.020. Evidence Level V.

Zembrzuski, C. (1997). A three-dimensional approach to hydration of elders: Administration, clinical staff, and in-service education. Geriatric Nursing, 18(1), 20–26. doi:10.1016/s0197-4572(97)90126-9. Evidence Level V.

Zembrzuski, C. (2006). Oral fluid intake and the effect on postural blood pressure and falls in skilled nursing facility residents (dissertation, p. 176). New York: New York University. Evidence Level IV.