An estimated 1,000 children under the age of five years old die every day because they have no access to safe water. Access to clean drinking water is a basic human right and is essential to support life. Without water, death occurs quickly. As a rule of thumb, a human can go without water for three days. This, of course, will vary according to age and medical history.
In the Western world, we have perhaps become too used to the convenience of turning the tap on for a drink whenever we are thirsty. But what if you can’t turn on a tap; what if you aren’t able to access a drink? No-one goes thirsty in the developed world—do they? What does dehydration have to do with end of life care?
Do you have an elderly relative in a care/nursing home or hospital, or perhaps you have a relative who has sustained a spinal injury and is immobile? Maybe your relative has had a stroke and is confused. When did your loved one last have a drink; do you know? Even if your relative has water close by, can they reach it to drink it? Don’t assume your loved one has had, or has been offered, a drink recently.
Dehydration doesn’t discriminate and affects all ages. Many suffering from a mental health illness, or those with a learning disability, forget to drink and dehydrate. Similarly, those suffering from spinal injuries and fractures may also be unable to reach a drink if they are not helped.
Is your loved one dying of thirst? Has your loved one been put on an ‘end of life care’ pathway? Would you even be told if your loved one had been placed on end of life care?
Many patients who are dehydrated get confused. If a patient becomes too confused or agitated, they will neither remember nor attempt to drink. To ameliorate confusion, they may be prescribed sedatives. When a patient is sedated they cannot access or ask for a drink. As a person gets too drowsy to drink, fluids may be discontinued and the patient is diagnosed as “imminently dying”. Many are dying because they are being neglected, not because they are terminally ill. Could something as simple as a glass of juice or water have saved their life?
Midazolam
Midazolam is a short-acting benzodiazepine used for minor procedure and surgery sedation. However, Midazolam is also considered one of four essential end of life care medications and is often used in the elderly in combination with opioids. Midazolam is often administered by a syringe driver or pump. If your relative is attached to a pump, ask what medication is in it and the reason for its administration. Many experts do not recommend the use of Midazolam in the elderly, as it depresses respiration. Combined with an opioid, it is lethal.
Who is at risk of dehydration?
Firstly, we should identify some of the groups in the community who may be unable to access, or request, a drink for themselves, who and may be at increased risk of dehydration.
- Babies and the very young
- All ages—Chronic mental health illness/learning disabled
- All ages—Physically disabled or paralysed
- All ages—Fractures of spine and hip, rendering person immobile or even paralysed
- Unconscious
- Bed-bound
- Elderly
- Elderly confused/Dementia
In 2024, in the United Kingdom, it appears that thousands of our most vulnerable members of society are being denied access to water and are literally dying of thirst. One study has shown that 31% of patients in long-time care were dehydrated. Patients who are dehydrated are six times more likely to die in hospital that those who are not dehydrated.
What is dehydration?
The human body has many functions to perform and water is essential for all of them. Water is vital to:
- Regulate temperature
- Eliminate waste
- Delivers nutrients to cells and lubricates the joints
- Blood oxygen delivery
- Skin hydration
- Cognitive function including memory function
The body is very clever. When it detects that it needs more water, it alerts the limbic system in the brain to make you feel thirsty. Your body will then try to conserve water and even your kidneys will drop down a gear in order to preserve it. You may notice your urine colour becoming darker and more concentrated. The body loses water in a number of ways: in sweat, urine and even in your breath.
Electrolytes
When the body loses water, it also loses electrolytes. Electrolytes are minerals: sodium, potassium, chloride, magnesium, calcium, phosphate and bicarbonates—all essential to maintain life. A drop in electrolytes can cause muscle weakness, cramping, headaches, confusion, irregular heartbeat and nausea. Electrolyte replacement therapy can be bought from most pharmacies; some may recognise the brand Dioralyte. Most people will be able to maintain their electrolyte balance by eating a healthy and varied diet.
Feeling thirsty
When our bodies begin to become dehydrated, we experience thirst. However, as we become older, our sense of thirst weakens. Many of the elderly drink less water than younger people, and can often become dehydrated before feeling thirsty. Those with a diagnosis of dementia or Alzheimer’s disease, or those who have suffered a stroke, will also have a significant reduction in feeling thirsty or being able to swallow. Most will need reminding, encouraging, supervising and helping with drinking regularly, and a record of all fluid intake should be kept.
Diuretics and incontinence—Water pills
Diuretics are more commonly known as ‘water pills’, although they can be administered by injection too. Diuretics are medications that increase the amount of water and salt expelled from the body as urine. Diuretics increase the need to urinate, and many experience urgency and may require help to access a toilet. Many with high blood pressure or congestive cardiac failure will be treated with diuretics, as they will help decrease the amount of fluid building up in the body.
Diuretics reduce the amount of fluid in blood vessels, which in turn will lower blood pressure and will help decrease the amount of fluid build-up in the body. However, it is worth noting that many who are elderly or immobile, and who are taking diuretics, are often unwilling to drink, worried about incontinence and not being able to access a toilet quickly enough. Many may feel a burden or a nuisance to carers or family. An unwillingness to drink will quickly lead to dehydration.
Care homes and hospitals
Many in nursing homes residential homes and hospitals will become dehydrated because they are reliant on carers and nursing staff for drinks. Dehydration will, if not corrected, lead to confusion and a rapid decline in cognitive function. Even those who are mobile, and who have access to fluids, may forget to drink. It is vital that a fluid balance record is kept. Many care homes have policies in place for monitoring fluid intake—but it is up to relatives and visitors to request the information.
Many medical conditions that require a hospital admission can lead to dehydration, such as diarrhoea, fever and diabetes, which can further exacerbate fatigue, headache and constipation. Dehydration can also lead to a urinary tract infection or acute kidney injury.
Digitisation has removed the need or requirement for paper fluid balance charts, measuring fluid intake and output. These would previously have been found hanging from the end of a patient’s bed or on their door, making it easy for relatives and visitors to monitor without needing to ask staff. It remains the responsibility of the staff to ensure drinks are offered, accepted and recorded regularly.
Signs of dehydration in the elderly and vulnerable
- Dry or/and cracked lips
- Dry mouth
- Poor pronunciation of words
- Dryness of skin
- Infrequent need to pass urine/dark amber-coloured urine
- Strong-smelling urine
- Muscle cramps
- Confusion
- Headaches
- Irritability
- Poor memory
- Dizziness
- Headache
- Fainting
- Increased heart rate
The effects of dehydration in the elderly and the vulnerable can be rapid and urgent action should be taken. Rehydration often leads to a rapid recovery. Often, within fifteen minutes of receiving a drink, symptoms should start to improve.
Simple test for dehydration—pinching skin on back of hand
There are blood tests to determine dehydration, but a reliable and quick way to determine whether someone is dehydrated is to gently pinch some skin on the back of the hand and then release it. If the skin bounces back quickly, that is a sign that hydration is sufficient. However, if the skin stays in a peak and is slow to return to the surface of the hand, this is an indication of dehydration.
Treatment of dehydration
The treatment for dehydration is rehydration. Depending on circumstances, if drinking becomes too difficult, often an intravenous infusion will be in place. Check the chamber to see how quickly the drops are running. Are they running too slowly? The majority of patients requiring an intravenous infusion will also have a urinary catheter connected to a catheter bag. How much urine is in the bag and when was it last emptied? For those who are able to swallow, encouraging, supervising and helping to give two-hourly drinks will improve both physical condition and brain cognition.
How to prevent dehydration in the elderly and vulnerable
Public awareness of dehydration is the only certain way to prevent dehydration. Knowledge saves lives. No -one should be thirsty. Dehydration leads to confusion, which may be treated with sedative medications. Patients who are sedated aren’t able to access drinks, which leads to further dehydration—and so the vicious cycle continues, until death. Dehydration is easily reversible and need not be serious. Be vigilant, ask questions and share the message.
Fresh water should always be available and within easy reach for everyone. Milk, orange juice and commercially prepared electrolyte replacement drinks are known to be helpful in preventing dehydration.
How to encourage a reluctant drinker
Sometimes, it can be difficult trying to encourage others to drink. Some may find holding a glass difficult, so may require a drinking beaker or a straw. Freshly-chilled water, presented with a slice of lemon or ice, is often more appealing and palatable.
Frozen flavoured ice pops are also an attractive alternative for those who may be feeling weak or suffering from nausea. Fruits and soups can also contribute to daily fluid intake.
Keep drinks in suitable containers (beakers or water bottles), visible at all times. There should be no excuse to forget or not be able to reach a drink. Routines to encourage drinks will be helpful: for example, pouring a drink with a meal and ensuring it is drunk, drinking a full glass of water/juice with medications, or perhaps you could join them for a drink or a cup of tea.
Regular monitoring and record-keeping is the only reliable way to know whether your loved one is drinking enough. Engage with staff.
Essential resource for relatives
- The Dehydration Lifeline was set up by physicians to inform and alert relatives of the dangerous consequences of dehydration. The Dehydration Lifeline is a lifesaver; please share this valuable resource. Not only is it a lifeline, it is a lifesaver.
- Together
- Debate on End of Life Care and Protocols
- Professor Father Patrick Pullicino, retired consultant neurologist
Please note:
Dehydration symptoms in adults who are in their senior years aren't always clear-cut. For example, some medications can affect the colour of urine. Also, although dehydration can cause hallucinations in the elderly, cognitive changes from dementia or even side effects from certain medications are also sometimes responsible for the experience of perceiving things that aren’t there.
