Strategies for Ensuring Good Hydration in The Elderly
Literature review by Wendy Wells, NMD.
Dehydration is a frequent cause of illness and death in elderly people. It causes the hospitalization of many patients and its outcome may be fatal. Indeed, dehydration is often linked to infection, and if it is overlooked, the chance of death exceed 50%. Older individuals have been shown to have a higher risk of developing dehydration than younger adults. Modifications in water metabolism with aging and fluid imbalance in the frail elderly are the main factors to consider in the prevention of dehydration. Particularly, a decrease in the fat free mass, which is hydrated and contains 73% water, is observed in the elderly due to losses in muscular mass, total body water, and bone mass. Since water intake is mainly stimulated by thirst, and since the thirst sensation decreases with aging, risk factors for dehydration are those that lead to a loss of autonomy or a loss of cognitive function that limit the access to beverages. The prevention of dehydration must be multidisciplinary. Caregivers and health care professionals should be constantly aware of the risk factors and signs of dehydration in elderly patients. Strategies to maintain normal hydration should comprise practical approaches to induce the elderly to drink enough. This can be accomplished by frequent encouragement to drink, by offering a wide variety of beverages, by advising to drink often rather than large amounts, and by adaptation of the environment and medications as necessary. Nutritional Review. 2005 Jun;63(6 Pt 2):S22-9. Ferry M. Center Hospital University
Some sodium, potassium and water changes in the elderly and their treatment.
Creatinine clearance decreases with age by 1 ml/min/year after 40 years of age, although serum creatinine remains constant because of reduction of muscle mass. Reduction of water intake may occur in the elderly because of a reduced sensation of thirst; this is associated with a tendency to lose water with urine. The capacity to respond to sodium load is impaired in aged kidneys, thereby leading to extra cellular volume (ECV) expansion and hypertension. But there is also, in the elderly, a reduced capacity for retaining sodium (FENa is higher than in young subjects), making old subjects sensitive to salt depletion and ECV contraction. Hypernatraemia (Nas > 150 mmol/l) is not infrequent in the elderly (1%) and is usually due to water deficiency (old subjects should be forced to drink), and rarely to iatrogenic excess of sodium. It is the abrupt occurrence of severe hypernatraemia that causes neurological symptoms due to dehydration and brain shrinking, which may lead to cerebral haemorrhage and death. Hyponatraemia (Nas < 130 mmol/l) is frequent among the elderly (7-11%) and is mainly due to water overload, which is usually iatrogenic. Hypovolaemic hyponatraemia occurs when salt depletion causes ECV contraction > 10%, and is due to water retention in an attempt to normalize ECV. Hypervolaemic hyponatraemia is due to ADH hypersecretion because of a decrease in 'effective' circulating blood volume. 'Pseudohyponatraemia' may occur because of hyperlipidemia or hyperproteinaemia. It is the abrupt occurrence of severe hyponatremia that causes neurological symptoms (water intoxication), secondary to the oedomatous swelling of the brain within the skull. While rapidly occurring hyponatremia may be lethal, slowly occurring hyponatremia is usually asymptomatic. Rapid correction of hyponatremia may cause cerebral dehydration and 'osmotic demyelination syndrome' ('central pontine myelinosis'). Decrease (e.g. by diuretics) or increase (e.g. by ACE-inhibitors, non-steroidal anti-inflammatory drugs, beta-blockers) or serum potassium may occur in the elderly. Diuretics should be used with caution in elderly subjects to avoid salt depletion, hypotension and renal function impairment.Semin Nephrology 1996 Jul;16(4):277-88.
Abnormalities of water metabolism in the elderly.
Hypernatremia (high sodium in the blood that occurs with excessive fluid loss) is a frequent problem at the extremes of age, but particularly so in elderly individuals. Changes in the physiological responses to water deprivation with increasing age may be of particular interest in understanding the pathogenesis of hypernatremia in the elderly. When comparing healthy elderly men to younger controls, there are differences in the response to water deprivation. In older men, there are deficits in both the intensity and threshold of the thirst response. The ability to concentrate the urine also declines with age. There is both a decline in glomerular filtration rate and an increased incidence of renal disease with advancing age, which may contribute to impaired ability to conserve water. Because of a decrease in the percent total body water with age, equal volumes of fluid loss in young and old individuals may represent more severe dehydration in the elderly. Hyponatremia is seen in all age groups, but there are important differences in the elderly. When compared with postmenopausal women, menstruant (of childbearing age) women are over 25 times more likely to suffer permanent brain damage as a complication of hyponatremic encephalopathy. Furthermore, menstruant women suffer seizures or respiratory arrest at far higher levels of plasma sodium (110 to 130 mmol/L) than occurs in postmenopausal women (95 to 123 mmol/L). J Clinical Endocrinol Metabolism. 2001 Dec;86(12):5996-7.
Potassium depletion and salt sensitivity in essential hypertension.
To evaluate the actual role of potassium depletion on blood pressure, 11 hypertensive patients were placed on a 10-day isocaloric diet providing a daily potassium intake of either 18 or 80 mmol, with each subject serving as his or her own control; the intake of sodium (220 mmol/day) and other minerals was kept constant. On day 11 each patient was also subjected to central volume expansion by water immersion associated with either normal or low potassium intake. After a 10-day period of low potassium intake, systolic blood pressure increased (P < 0.02) by 5 mm Hg, whereas serum potassium decreased (P < 0.001) by 0.9 mmol/L; no significant changes in urinary sodium and a marked increase in urinary calcium excretion (P < 0.001) were found during the 10-day low potassium intake. PRA (P < 0.02) and plasma aldosterone (P < 0.04) concentrations also decreased during low potassium intake in hypertensive patients. Even though an identical natriuretic response was found during the water immersion experiments with either high or low potassium in the whole hypertensive group, the evaluation of hypertensive subjects in relation to salt sensitivity enabled us to disclose pronounced differences in the natriuretic and calciuretic response. In fact, although an impaired natriuretic ability and moderate calcium loss were particularly found during water immersion in those hypertensive subjects exhibiting a lower salt sensitivity index, a predominant calcium depletion appeared to be the most important consequence of potassium depletion in the hypertensive subjects with a higher salt sensitivity index. By confirming that potassium depletion may exacerbate essential hypertension, our data also suggest that not only sodium restriction, but also potassium and calcium supplementation, could be particularly advisable in salt-sensitive hypertensive patients. Clin Experimental Hypertens. 2005 Jan;27(1):95-112.
Potassium, magnesium, and electrolyte imbalance and complications in disease management.
Electrolyte balance is a critical issue in managing comorbid conditions in both diseased and elderly patients. Patients with hypertension and diabetes need careful regulation of their calcium and magnesium levels, whereas in patients with congestive heart failure, sodium and potassium levels also are critical. Herein we report the outcome of a round table discussion at which issues of renal magnesium clearance, magnesium and arrhythmic risk, ion balance in heart failure, diabetes, ischemic stress, oxidative stress in the cardiomyopathy of magnesium deficiency, roles of magnesium and potassium in bone metabolism and the aging population, and the role of electrolyte balance in hypertension have been discussed. In all these issues the maintaining homeostasis of potassium and magnesium is critical and the various therapies that impact on retaining these ions were discussed. Hallmark studies, i.e., Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial and Studies of Left Ventricular Dysfunction, have provided insight into treatment of patients with cardiovascular and progressive heart failure. These studies and the availability of potassium and magnesium sparing diuretics for use in these disorders provide relevant perspectives for treatment.
Hyponatremia is the most common electrolyte imbalance. It is associated with kidney disease such as nephrotic syndrome and acute renal failure (ARF). Men and women with healthy kidneys have equal chances of experiencing electrolyte imbalance, and people with eating disorders such as anorexia and bulimia, which most often affect women, are at increased risk. Very young people and old people are affected more often than young adults.
Causes of Hyponatremia
Hyponatremia is caused by conditions such as water retention and renal failure that result in a low sodium level in the blood.
Pseudohyponatremia occurs when too much water is drawn into the blood; it is commonly seen in people with hypoglycemia (low blood sugar).
Psychogenic polydipsia occurs in people who compulsively drink more than four gallons of water a day.
Hypovolemic hyponatremia (with low blood volume due to fluid loss) occurs in dehydrated people who rehydrate (drink a lot of water) too quickly, in patients taking thiazide diuretics, and after severe vomiting or diarrhea.
Hypervolemic hyponatremia (high blood volume due to fluid retention) occurs in people with live cirrhosis, heart disease, or nephrotic syndrome. Edema (swelling) often develops with fluid retention.
Euvolemic hyponatremia (decrease in total body water) occurs in people with hypothyroidism, adrenal gland disorder, and disorders that increase the release of the antidiuretic hormone (ADH), such as tuberculosis, pneumonia, and brain trauma.
Signs and Symptoms of Hyponatremia
Symptoms of hyponatremia are related to the severity and the rate at which the conditions develop. The first symptoms are fatigue, weakness, nausea, and headache. More severe cases cause confusion, seizure, coma, and death.
The goal of treatment is to restore electrolyte balance for proper hydration and use of total body fluid. Sodium deficiency must be corrected slowly because drastic change in sodium level can cause brain cell shrinkage and central pontine myelinolysis (damage to the pons region of the brain). Methods include: Fluid and water restriction; Intravenous (IV) saline solution of 3% sodium; Salt tablets.
Hypernatremia is high sodium in the blood that occurs with excessive fluid loss. When fluid is lost and not replaced, sodium is not adequately excreted from the body. The following are causes:
Diabetes insipidus (caused by deficiency of or insensitivity to ADH):
- Diuretic medication
- Excessive salt intake
- Excessive vomiting
- Heavy respiration (e.g., exercise, exertion)
- Severe burn
It is associated with the same symptoms as hyponatremia, and also causes the following:
- Muscle twitching
Hypernatremia commonly affects older hospitalized people, 50% of whom have underlying diseases that, when combined with excessive sodium and fluid loss, are fatal.
Treating hypernatremia involves slowly replenishing water loss, usually over 48 hours, through drinking or intravenous (IV) solution. In cases of diabetes, the imbalance is treated with adequate water intake and nonsteroidal anti-inflammatory drugs or with synthesized hormones (e.g., desmopressin) that aid in fluid retention and decrease urination.
Some drugs used to treat electrolyte imbalance may be unsafe for pregnant women and should not be taken before consulting a physician.
An abnormally low level of potassium (K+) is called hypokalemia. The adrenal gland makes a hormone (aldosterone) that signals the kidneys to excrete or conserve potassium, based on the body?s needs. In hypokalemia, the adrenal gland retains the hormone and the kidneys conserve potassium when more is needed.
The most common cause of potassium depletion is diuretic medication that increases urination. Diuretics are prescribed for medical conditions and are used in weight-loss programs. Other causes include:
- Dietary deficiency
- Excessive sweating
- Magnesium deficiency (causes overexcretion of fluid)
Signs and Symptoms
Symptoms of deficiency include cardiac arrhythmia, muscle pain, general discomfort or irritability, weakness, and paralysis.
Diagnosis may require urinalysis and blood tests to determine the amount of potassium being excreted by the kidneys.
Treatment involves potassium supplements, proper diet, and intravenous (IV) solution. The best way to maintain an adequate potassium level is to eat foods such as sweet potatoes, bananas, avocados, spinach, and oranges. Patients taking diuretic medication are also given potassium supplements. Potassium is given slowly to avoid hyperkalemia.
An abnormally high level of potassium is called hyperkalemia. Potassium is released into the blood when cells are damaged.
Conditions that cause hyperkalemia include:
- Hemolysis (red blood cell destruction caused by infection or burn)
- Rhabdomyolysis (destruction of skeletal muscle; associated with acute tubule necrosis, or ATN)
- Strenuous exercise (rarely)
Urinary excretion of potassium can be impaired by the following:
- Acute renal failure (ARF)
- Chronic renal failure (CRF)
- Impaired aldosterone release or production
- Medications that decrease potassium excretion: Amiloride (diuretic), Bactrim?(antibiotic), Cyclosporine (immunosuppressive)
Signs and Symptoms
Hyperkalemia affects the heart and causes electrocardiogram (EKG) changes, ventricular fibrillation, and cardiac arrest. Other symptoms include tingling in the extremities, weakness, and numbness.
Treatment of low-grade hyperkalemia may involve diuretics and calcium given intravenously to promote potassium excretion. Insulin is given with glucose to help cell absorption of potassium, and albuterol may be added to increase absorption. Drugs that bind to potassium, such as Kayexalate?, force potassium into the intestine to be excreted.
Some drugs used to treat electrolyte imbalance may be unsafe for pregnant women and should not be taken without consulting a physician.
Reviewed by Wendy Wells April 2013
Less active elderly patients want to drink less because it makes them have to "move" to have to get to the bathroom. However, the more active elderly do not have this issue. Staying active is of upmost importance. If one's thirst changes, I recommend using other means of checking for dehydration such as pinching the skin on the back of the hand to check how fast the skin returns to its normal position. Or touching the lips to see if they are dry.
There are lots of ways to make drinking water fun, having herbal tea, mixing juice with water, or electrolyte drinks are some of the most popular ways. A good rule of thumb, if a patient is thin and dehydrated I think they may need salt, if they have swollen ankles, I think potassium. Blood work can reveal the whole story however. When looking at electrolytes in the blood panel, results at the high or low end of normal can be enough to lead to deficient or excess signs and symptoms.
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