Hacking Hydration this summer: A guide for Care Partners

Proper hydration is always essential, but especially for aging adults who might not be acutely attuned to their body’s thirst cues.

“The sensation of thirst declines as people age. Older adults — regardless of cognitive function — may not realize that they are thirsty even though they’re not drinking enough,” said Gretchen Tanbonliong, the National Council on Aging’s Associate Director of Health and Wellness. “People living with dementia may experience similar changes, but they may be less able or likely to get themselves a drink, especially if they’re unable to communicate or recognize that they’re thirsty, or if they forget to drink. This is a problem because their risk for dehydration increases.”

ADRC Director of Communications and Media Robin Rountree shared a similar sentiment in an episode of the Informed Aging podcast, titled “The Heat and Your Health,” recorded July 2024.

“Studies show that it can be hard for even healthy older adults to tell when it’s too hot, or if they’re dehydrated,” she said. “Add in cognitive decline, you’re gonna get more problems. Older bodies hold more heat than younger ones when the temperature climbs, and our older glands don’t release as much sweat. The heart doesn’t circulate blood as well, so heat is less (able) to release from the vessels in our skin.”

As the heat index ascends, it’s critical that Care Partners examine the signs and impacts of dehydration, as well as nutritional and behavioral prevention strategies that specifically target older adults living with some form of dementia.

So, what are the signs of dehydration?

Symptoms might manifest as cracked lips or dryness of the skin, tongue, or mouth, Tanbonliong says, and Care Partners might notice that their person’s skin elasticity might seem compromised.

“If you pinch the skin on your arm, for example, it takes longer for your skin to return to its usual position,” she says. “Normally it should spring back within a second or two.”

Dehydration might yield fatigue, weight loss, and an increase in the body’s overall temperature or heart rate, Tanbonliong adds.

Dark urine also signals dehydration.

“At the risk of being a little bit TMI, when you drink enough water, the color in the bowl… should be very, very pale, almost nonexistent. If you’ve got some deep color going on there, or even a noticeable color, drink more water,” said Edith Gendron, who facilitates ADRC’s Dignified Dementia Care: A Partnership series, in the podcast episode with Rountree. “And that’s tough stuff when we’re working with somebody who has some form of dementia…UTIs are bad news and that can be part of it, right?”

Urinary tract infections, kidney stones, gallstones, and constipation are all possible results of dehydration, Tanbonliong says.

Dementia Care Specialist Teepa Snow says that depleted fluids means less blood-flow to the brain, increasing the risk for stroke, heart attack, and coagulation.

There is also the potential for tissue damage, falling and sustaining injuries, passing out, and experiencing “acute confusion,” she notes.

In fact, confusion, and other cognitive challenges — slurred speech, short-term memory difficulties — are all indicators that dehydration is at play, although they might be mistaken for dementia symptoms, Tanbonliong says. Psychologically, people who are dehydrated may exhibit irritability or depression, which can also be misunderstood as dementia-related features.

“Dehydrated cells are associated with brain dysfunction,” Tanbonliong says. “Decreased water levels in cells can cause proteins to misfold and prevent the clearance of these toxic proteins, causing them to build in the brain. In older adults, prolonged dehydration may promote continued cognitive decline. However, we do not know yet whether dehydration is a cause or effect of dementia.”

So, how do we prevent dehydration?

“I think of a Florida summer as I used to once think of a New York or Maine winter,” Gendron said. “You stay in, you stay as cold as you can — where you stayed as warm as you could there. You eat certain things that are cold and come out of the refrigerator. You avoid the stove and the oven. You avoid outdoor activities, even so far as gardening.”

Tanbonliong suggests a two-pronged approach to maintaining sufficient hydration that includes both nutritional and behavioral strategies.

“Although plain water is an excellent calorie- and sugar-free choice for staying hydrated, one could try making these refreshing, water-based beverages at home by adding any of the following to a cold glass or pitcher of water — sliced citrus fruits or zest (lemon, lime, orange, grapefruit); crushed fresh mint; peeled, sliced fresh ginger or sliced cucumber; crushed berries,” she says.

While coffee, sodas, and sweet tea may be beloved drinks, it’s important to be mindful that sugar and caffeine reduce hydration, Snow says, noting that decaf or partial decaf are better options.

“A healthier alternative to soda is homemade sparkling juice which can be made with 12 ounces of sparkling water and just an ounce or two of juice,” Tanbonliong says.

It’s also a good idea to avoid alcohol.

Care Partners should pay attention, too, to the water temperature, as some people don’t like drinking cold beverages, Snow says, and they should look for signs of difficulty swallowing, like coughing, if their person has a resistance to hydration.

In addition, it’s helpful to remember that liquids are not the only way to boost our water consumption.

“In fact, about 20% of our total water intake comes from foods with high liquid content such as milkshakes, ice cream, yogurt, sherbet, fruit ice, popsicles, soups, stews, fruits and vegetables — all of which count towards our daily fluid intake. It would be a good idea to offer these additional fluid sources at meals or as a snack,” she says.

Watermelon or jelly drops are also optional offerings, Snow says.

Care Partners can also implement slight behavioral and environmental modifications that encourage adequate hydration.

“Encourage small sips of fluid throughout the day,” Tanbonliong says. “Keep beverages within reach and assist with drinking as needed.”

Hydration ultimately becomes routine when Care Partners notice opportunities to increase fluids, Snow says. This might mean offering water or water alternatives prior to giving medication or after using the bathroom, completing exercise, washing their hands, doing dishes.

“Any time you’re near water, it’s an opportunity if the water is drinkable,” Snow says, noting the verbiage might look something like, “While we are here, let’s get a drink so we don’t have to later.”

Tanbonliong even suggests setting hydration reminders on a smartphone or smartwatch.

Appropriate timing is especially significant if incontinence is an issue.

“Rather than cut back on fluids due to incontinence, consider when and what to drink,” Tanbonliong says. “The goal is to spread fluid intake evenly throughout the day to stay hydrated. Limiting fluids an hour or more before bedtime will help prevent unwanted trips to the bathroom at night. Also, some beverages can stimulate the bladder, such as alcohol, coffee, and caffeinated tea.”

A “bladder diary” is an expert-approved way to observe fluid consumption and urination patterns that might influence necessary routine shifts, she adds.

When it comes to approaching their people, Care Partners might swap the “Are you thirsty?” question with a toast — sitting and sipping a drink of their own so that the activity becomes a shared moment.

They might offer a beverage and the suggestion, “Taste this and see what you think,” Snow says.

“(We want to) make sure we are hydrating well and make that a partnership,” Snow says. “(We are always) looking at ways we can make it feel friendly and natural.”

She notes that multiple small cups seem to work best.

Tanbonliong adds that a clear cup or glass is beneficial because it allows people to see the liquid.

“Or try a brightly colored cup to draw attention instead. Make sure it’s not too heavy or a difficult shape,” she adds.

It’s also essential that Care Partners note the various medications their person is taking, as some pharmaceuticals might exacerbate photosensitivity and the heat’s overall impact.

Snow suggests involving the doctor, who can determine if the current drug regiment should be tweaked as summer approaches.

“It is important to note that many older adults live with one or more chronic disease conditions such as diabetes and kidney disease which increase the risk of dehydration,” Tanbonliong says. “They may also take certain medications… which promote water loss. All these — combined with age-related changes in our body’s capacity to store water — impact hydration status.”