Dehydration risk factors and outcomes in older people in rural areas

Dehydration among the elderly is a neglected health concern that is one of the most common silent plagues. Dehydration is defined as a reduction in total body water volume, and it is considered severe when >3% of body weight is lost. However, determining how much weight has been lost and if it is all due to water loss can be difficult. Dehydration is commonly seen when biochemical indicators and clinical features change.¹

Sweating, urine, and exhaling during breathing are all ways in which water is lost. Dehydration in the elderly is prevalent for several reasons: some medications are diuretics or cause patients to sweat more. A person’s sense of thirst gets less intense as they age. As the bodies of elderlies lose renal function, they are less able to preserve fluid. Dehydration in the elderly can be caused by an illness that produces vomiting and diarrhea.^2–4 Some older individuals intentionally limit their water intake to cope with incontinence. In contrast, others may not drink enough to meet their fluid requirements because their mobility is compromised to the point where they are unable to obtain something to drink.^5,6

Acute illnesses such as pneumonia, urinary tract infections, and various chronic conditions are risk factors for dehydration in the elderly. Also, fever, diarrhea, vomiting, any major surgery, gastrointestinal bleeding, swallowing problems, and certain medications (diuretics, laxatives, and some heart medications) may trigger dehydration.⁷ People with mild to moderate dehydration who can drink and are not experiencing severe mental or physical symptoms as a result of fluid loss may be able to replenish their losses orally. Fluids can be replenished through the mouth (orally), veins (intravenously), or a stomach tube depending on the person’s health. Dehydration might be a normal part of death that occurs due to old age.⁸

The demographic characteristics of the elderly studied are listed in Table 1, the findings revealed that 47% of the elderly were aged 60 to <65 years, 29.5% of the elderly were aged 65 to <70 years, 13.1% of the elderly were aged 70 to <75 years, 5.9% of the elderly were aged 75 to <80 years, and 4.3% of the elderly were aged ≥80 years, with a mean age (SD) = 67.475.95. Furthermore, men constitute 51% of the population, while women 49%. Among those polled, 68% are married, with 27.5% widowed. Only 2% of the population is single, whereas 1.3% is divorced. Among those who took part in the study, 93% had siblings. In terms of educational achievement, 55% of individuals can write or read, but just 4% can do both.

Table 2 represents the knowledge that the respondents had about dehydration. The first section is related to understanding the meaning of dehydration. Results showed that 291 (95.4) individuals among the elderly heard about dehydration problems; 94.1% correctly answered that dehydration happens when not having enough fluid. Also, 192 (63%) answered that dehydration occurs when a lot of fluids are lost. Regarding the prevention of dehydration, 268 (87.9%) sought to drink enough fluids (milk, juice, or water). Also, regarding the consequences of dehydration, 250 (82%) have the opinion that dehydration may lead to kidney disease. Figure 1 shows that the elderlies’ level of knowledge was distributed, as 40.3% of the elderlies had a low level of knowledge regarding dehydration. In contrast, 34.8% had a high level of knowledge regarding dehydration.

Figure 1.

Table 3 represents the distribution of the medications that increased the risk for dehydration: 81.3%, 80.3%, 77.7%, 65.9%, 29.8%, 14.8%, and 2.3% of the study subjects took anti-acids, anti-inflammatories, diuretics, laxatives, corticosteroids, antidepressants, and chemotherapy, respectively.

Table 4 shows that the mean score of physiological signs of dehydration among the elderly was 3.12 ± 1.70 out of the maximum score of 6. The mean score of clinical signs of dehydration was 3.46 ± 1.1 out of the maximum score of 7. The mean score of functional signs of dehydration was 6.65 ± 1.87 out of the total score of 9. The mean score of total dehydration risk among the elderlies participating in the study was 13.02 ± 4.05 out of the maximum score of 23.

A total score of risk for dehydration among study subjects was calculated to ascertain the risk for dehydration among the elderly people who participated in the study. The results, depicted in Figure 2, are the following: 38.7% of the study subjects are at low risk for dehydration, 52.5% at moderate risk, and 8.9% at high risk.

Figure 2.

Table 5 illustrates the relationship between different demographic variables and the risk for dehydration. There is a non-significant relation between age and risk for dehydration (X² = 14.708 and P = 0.065). There is no significant relationship between sex and the risk for dehydration (X² = 2.41 and P = 0.298). There is no link between marital status and the risk for dehydration (X² = 10.69, P = 0.098). There is no significant relationship between having children and the risk for dehydration (X² = 1.001 and P = 0.606), but there is a significant relationship between educational level and the risk for dehydration (X² = 63.490 and P = 0.000).

Table 6 shows that there was a statistically highly significant correlation between anti-inflammatory, anti-acid, and corticosteroid medication with the risk for elderly dehydration (P = 0.0001), and a significant statistical correlation between diuretics (P = 0.010), laxatives (P = 0.008), and antidepressants (P = 0.007) with the risk for elderly dehydration. In contrast, chemotherapy showed a statistically non-significant correlation with the risk for elderly dehydration (P = 0.795).

Given that intra- and interindividual variables may influence risk and the fact that there is no gold standard for quantifying risk for dehydration in ill or healthy persons, determining the risk for dehydration can be difficult.⁹ Measuring the elderlies’ exposure to dehydration is one of the basic tasks of the nurse responsible for providing care to the elderlies. Therefore, knowledge of the factors responsible for dehydration in the elderly is indispensable in such nurses, and they also need to measure and monitor these factors continuously to avoid the undesirable consequences of dehydration.¹⁰

The focus of the current study was the measurement of: (i) the risk factors for dehydration in the elderly; (ii) the level of information that the elderlies possess concerning dehydration and the relationship that this level bears to the occurrence of dehydration. The number of elderly participants who agreed to participate in the study was 305, and the average age of the participants was 67.47 ± 5.95 years, which is a reflection of the average age of the elderly in the Arab Republic of Egypt, given the fact that according to the last population census (the 2018 census), it was found that the average age of the population of elderlies in Egypt was 69.04. The study showed that the ratio of males and females was close, as more than half of the participants were males (51%), which is consistent with the Egyptian population report for the year 2018, and this indicates that there was no gender-specific obstacle to participation.¹¹

The majority of the study subjects were married, and close to a quarter were widowed; usually, residents of rural areas tend to adhere to the presence of a partner, and so it becomes clear that most of the elderly are either married or even related to a partner; this is the result of the rural cultural inheritance in Egypt, which emphasizes the importance of the partner, and this agreed with the results of the research by Mendoza et al.,¹² who explained that marriage in rural Egypt is an essential factor for seeking financial or social support, which is consistent with the results of this research. Also, most of the participants have children who take care of them in old age, which is one of the characteristics of the Egyptian countryside.

Concerning the level of knowledge regarding dehydration, the majority of elderlies had previously heard about dehydration; this is a result of their having lived through exposure to awareness campaigns for dehydration in children, through visual and audio communication means such as television and radio. Despite that, we noticed in the course of our interactions with them that they did not particularly mention dehydration as a serious potential cause for debilitation. However, awareness campaigns about dehydration for children have marginally succeeded in creating such awareness among people in the countryside.¹³

Despite this awareness, the results showed that 40% have a low level of information about dehydration. This is consistent with the study of Shaheen et al.,¹⁴ where the extent of public knowledge of the danger of dehydration and factors of its occurrence was measured, yielding results similar to the ones of the current research, where knowledge concerning dehydration was observed to be low across a large percentage of the interviewed elderlies. Additionally, the elderly, despite their knowledge of the dangers of severe dehydration, may still be at risk because of inadequate or missing knowledge in relation to certain other factors, such as the need to drink a sufficient amount of fluids and to compensate for lost fluids, as well as to not be exposed to direct sunlight, which, for many elderlies, is a constant risk factor owing to their regularly working in the fields.

The results of the present study show that elderly people take anti-acids in excessively large dosages or at frequencies that are too high. Anti-acids are drugs used to treat abdominal distension heartburn, and acid indigestion, which are all signs of excessive stomach acid. They are also used to reduce the symptoms of excess gas, such as belching, flatulence, bloating, and stomach/gut pressure/discomfort. Combining the active ingredient in an antacid (in most cases a proton-pump inhibitor, such as omeprazole) with aluminum can help manage diarrhea.¹⁵ In the intestines, aluminum-containing anti-acids bind to phosphate, a vital physiological component. This might result in low phosphate levels, which can contribute to dehydration in the elderly, especially if fluid intake is inadequate.¹⁶ The current study showed that the elderlies’ consumption of anti-inflammatory drugs can be ranked second only to their consumption of anti-acids. With regard to this aspect, the observations of the present study agree with those of Emerson et al.,¹⁷ who, in their study conducted in the United States principally dealing with the use of non-steroidal anti-inflammatory drugs (NSAIDs), emphasized the dangers of taking anti-inflammatories in the elderly. Prostaglandins, which are hormones that regulate blood flow to the kidneys, are inhibited by NSAIDs. NSAIDs can cause kidney damage or failure in people who have been dehydrated previously, especially youngsters and the elderly.^18–20

The present study supports the view that medication has a prominent effect on the risk for dehydration, as the results concluded a highly significant correlation between dehydration and intake of anti-acids, anti-inflammatories, and cortisone. Cortisone also causes disturbances in the balance of body fluids, causing fluid transfer from inside the cells to their outside, affecting the osmotic pressure of the cells, which leads to an increase in the risk for dehydration among the elderly.

Although diuretics are best known as a major cause of dehydration, in the present study, they were ascertained as the third-most common cause of dehydration in the elderly; the study showed a statistical relationship between diuretics and dehydration among the elderly. Diuretics, in general, trigger the kidneys to release greater sodium in urine, which then results in the removal of more water from blood, facilitating the removal of this excess water by urination.²¹ With less fluid in elderly veins, blood pressure decreases; this can also contribute to dehydration. Diuretics are medicines that significantly affect the fluid balance in the body, as they increase urine output, which leads to an imbalance in the balance of salts in the body, as well as the exit of fluids from inside the cells to the outside, which leads to an imbalance in the ratio of sodium and potassium in the body.^22–24

The study showed that more than half of the participants were moderately exposed to risks for dehydration (when measuring the risk factors). Also, one-tenth of the participants were highly exposed to risks of dehydration, which may be consistent with the insufficient knowledge of the elderly about the seriousness of dehydration and the presence of some chronic diseases that increase exposure to dehydration. Risk factors related to functional signs of dehydration came to the fore, including dependence on others for daily activities, decision-making disorders, and movement disorders.

The studies of both Bunn and Hooper²⁵ and Johnson and Hahn²⁶ are in agreement with the results of the present study; in their study of the signs of dehydration among the elderly, they indicated that elderly people who drink insufficient amounts of water are more prone to dehydration; and they attribute the dehydration to either the elderlies’ forgetfulness to regularly consume water or their frequent intake of medicines affecting the fluid balance in the body. Also, direct exposure to sunlight plays a role as a factor; it involves elderlies’ direct exposure to the sun arising from their need to go out into the fields and work during the afternoons; this factor becomes involved especially since they are rural inhabitants.

The study showed that half of the elderly respondents were diabetic, and that a medium level of information about dehydration was the one that largely prevailed in the elderlies (among the various levels formulated based on the questionnaire developed). The study also showed that, in general, the elderlies in the village were exposed to a moderate rate of dehydration; and a strong relationship was also demonstrated between taking various types of medication and the occurrence of dehydration.