Woman holding a glass of water

Dehydration is a very serious problem in all ages and has potentially deleterious consequences if not diagnosed and treated promptly. Dehydration is often encountered in the elderly, both in the community and long-term care settings and it is important to understand some basic principles to reduce the risk of dehydration in this sensitive age group. 

Water accounts for about 60% of body weight in an average human. Two-thirds of this water is located in the cells of the body and one-third is located extracellularly. Part of the extracellular fluid is in our veins and arteries (the intravascular space) and this is tightly regulated by complex mechanisms based on pressure and osmotic receptors. The total amount of water in our body depends on a fine balance between intake and output of fluids. 

Water can be lost from our body from the kidneys through urine production, the skin through sweating, the lungs through breathing and the gastrointestinal tract through defecation. The kidneys filter our blood (around 150 liters of fluid per day) but only 1% of that fluid (1.5 liters) are excreted normally as urine. This shows the remarkable capacity of our kidneys to ‘economize’ water in order to keep us alive. The same happens in the gastrointestinal tract where the six to seven liters of fluids that the intestine receives per day (adding up the amount of liquid we consume in our food and drinks, the salivary, gastric, pancreatic and biliary secretions), the amount of water in the feces is only around 100 ml. This is another amazing mechanism of water conservation in our body. Of course in cases of gastroenteritis this absorptive mechanism is disrupted and therefore one can become dehydrated within hours in cases of severe diarrhea or vomiting.

As mentioned above water is also lost through sweat – normally 500 ml per day, but this amount may be increased during a hot day or if the person has fever. Sweating is a thermoregulatory mechanism and one should always take into consideration the increased losses through sweating in a feverish patient. Finally, a small amount of water is exhaled through the lungs via respiration – around 200 ml per day. To summarize, dehydration can occur in cases of decreased intake of water or/and increased losses as may happen with conditions like vomiting, diarrhea, kidney problems, administration of diuretics, high fever, hot environment, etc.

How can someone assess body water loss and dehydration in general? In conscious adult patients with no cognitive impairment, dehydration would normally bring thirst and a desire to drink water to replenish the losses. The mechanism of thirst is based on complex systems that are triggered through specialized osmoreceptors and baroreceptors in the body that sense water loss. In cases of altered consciousness or impaired cognitive function as in dementia or even in other conditions, the mechanism of thirst does not function well. The patient may not feel as thirsty or may feel the thirst but may not be able to communicate this. Bedridden patients with motor disability may not be able to get to the water if it’s not within reach. Progressively with age these regulatory mechanisms start to fade gradually and therefore older persons exhibit a decreased thirst sensation and reduced fluid intake.

So are there any ways of detecting dehydration in the elderly patient with impaired cognitive status that will not communicate to us that he is thirsty? A good rough guide is to look at the tongue and its moisture. A moist tongue without furrows argues against the presence of dehydration, whereas a dry furrowed tongue is suggestive of dehydration, but not diagnostic as this can also happen due to other causes, such as mouth breathing, various drugs, salivary gland dysfunction and so on. Another sign of dehydration is the presence of a dry axilla. Finally, a more reliable sign for dehydration, is what is called postural hypotension, during which the patient becomes dizzy when he assumes an upright position and there is a drop in the blood pressure and a rise of his pulse rate.

The diagnosis of dehydration is associated with an increased in-hospital morbidity and mortality. Dehydration has been proposed as a quality of care indicator in long-term care facilities. The diagnosis of dehydration in a patient admitted to hospital from a nursing home may imply a failure in the quality of health care delivery. However, the difficulty in diagnosing dehydration in older populations results in dehydration performing poorly as a quality of care indicator.

It is paramount to prevent dehydration in the elderly, especially the ones who are totally dependent on care provided by others. Provision of 1500 ml to 2000 ml of water per day is sufficient for an average sized person. Water is contained in food, soups and beverages and therefore all this water should be calculated. Most community-dwelling elderly consume about 1000 ml per day. The problems are worse when an elderly adult is dependant on others to provide them with hydration. Giving water to patients that due to dementia or other conditions are not co-operative takes time and patience. Serious complications can occur when there is a danger of aspiration due to poor swallowing reflexes as often happens in people with neurodegenerative conditions. In cases like that, water should be given with extreme caution but often is not adequate. Using a thickening powder to change the consistency of the water facilitates swallowing, but often a feeding tube may be necessary in order to deliver fluids (and food) more safely.

Joyful adult daughter greeting happy surprised senior mother in garden

Things to reflect on after holiday visits with older adults

During the winter holiday season many of us were lucky enough to visit older relatives, while taking all the necessary precautions to keep ourselves and our loved ones safe from COVID-19. Festive gatherings are a big part of family life and something most of us look forward to every year. The holiday season is joyful and familiar yet complex and demanding at the same time. Grocery lists grow larger, meals become more elaborate, we interact with more people and there are a myriad of things to remember: calling all of our friends and family for holiday wishes, mailing all those cards and gifts etc. While this complexity is usually a welcome change from our normal daily routine, it can be challenging for many older adults and it can often highlight health issues that would otherwise have remained undetected during the rest of the year.

Familiarity and repetition make our lives easier as most of us settle into our habits and daily schedules. These schedules, reinforced through daily repetition, become second nature to us and allow us to lead complex lives with minimal effort. Furthermore, their familiarity makes us feel safe and in control. Indeed, they provide us with a controlled and safe daily life even during those times when we might be physically or mentally exhausted and unable to expend much thought or effort on our daily chores. Normally we can cope easily with deviations from our set schedules and habits with a bit of effort and we often relish this change as something novel and refreshing. That’s why people go on holidays and take up new hobbies. At the same time, older adults are often faced with health issues that can affect their body and mind and therefore their ability to cope with change in their daily lives. In that case, change is no longer refreshing and inability to cope with it can lead to disturbances in an older adult’s daily life. Thus, many older adults may stick to familiar routines and schedules in order to mitigate the effect of health issues on their lives and furthermore they are often unaware that they’re using familiarity as a means to mitigate the effects of declining health.

Declining health can often remain invisible due to the often-reduced demands of our usual daily life but also due to its usually gradual nature. Older adults themselves and people sharing the same home with them may often fail to spot the decline as it is usually mitigated by subtle changes in activities and routines that often go unnoticed. People who visit an older adult sporadically on the other hand may be able to spot decline more easily as the changes may be more pronounced in the span of many weeks or months. Thus, people who visit their older relatives sporadically should be on the lookout for signs of decline especially during the holiday season which places increased demands and stress to older adults. There are many signs one should look out for but most of them fall under the following categories:

  1. Home environment: Modern living is complex and taking care of all the chores around the house can be physically and mentally demanding. As people cope with declining health, they tend to neglect chores starting from the ones that are less important for their daily functioning. As decline progresses one can neglect more chores to the point where they might be unable to live safely on their own. One should always use a person’s previous status as a reference point. An unkempt lawn might not be concerning if that person never cared about lawn maintenance but it can be a warning sign if that person used to have a pristine lawn a few months ago. The same is true for general tidiness around the house. On the other hand, expired medication, scorched cookware and spoiled food indicate behaviors that can present clear danger to the health and well-being of the individual regardless of their previous status. Changes in the home environment are usually easy to spot so they are often the first signs of decline noticed by friends, family and acquaintances.
  2. Physical appearance and grooming: The way our loved one looks and dresses can also alert us to possible decline. Significant weight loss often accompanies physical and cognitive decline. An older adult may lose weight due to illness or through the effects of medication. At the same time, cognitive decline can make the preparation of a meal too challenging and confusing for an older adult and even cause them to neglect eating. Unkempt appearance, dental issues and a general lack of hygiene can also signify possible cognitive decline as the older adult may be experiencing difficulties in dressing and grooming and they may be forgetting or be unable to bathe and brush their teeth.
  3. Balance issues and fear of falls: Balance and gait issues are very common signs of decline in older adults. An older adult may have difficulty maintaining their balance and they may compensate by changing walking patterns so they are close to things they can lean on or hold on to in case of unsteadiness. Their gait can grow shorter and they may limit walking to mitigate the possibility of a fall. As an older adult may sometimes be unwilling to admit or discuss their balance issues and fear of falling, noticing such early signs of mobility issues can allow a relative to open up the subject and help the older adult get the appropriate care, support and physical rehabilitation if needed.
  4. Mental and cognitive issues: Changes in cognition and mood can signify the onset of neurodegenerative diseases such as dementia or mood disorders such as depression. Depression in older adults often goes undiagnosed since the person experiencing it may not feel or exhibit the usual sadness that people often associate with depression. It usually appears in subtler ways which include withdrawal, loss of interest in hobbies and favorite pastimes and a lack of interest for house care and personal grooming. At the same time sudden mood swings and/ or aggression can be a sign of mental or cognitive disorders and they may also be caused by physical issues such as dehydration and improper use of prescribed medicine. Mental and cognitive disorders can be frightening thus when someone is worried that an older adult might be suffering from them it is best to reach out to a brain health expert for a thorough assessment so they and their loved ones can receive appropriate care and support.

The holiday season is first and foremost a time to relax and spend time with our loved ones. We all need time to enjoy ourselves, worry less and get away from all the things that are stressing us. This holiday season doesn’t have to be stressful and being vigilant about the health and well-being of our loved ones doesn’t mean we should over-analyze everything and stress about every little detail. If we trust or instincts, our knowledge and our connection with our loved ones, we can go on enjoying the holidays with them while remaining alert enough to spot any obvious or worrying changes.

What can I do? 

  • As an older adult: Be willing to hear the concerns of your loved ones. Don’t view any possible health issues as weaknesses or personal shortcomings. They can be frightening or exhausting at times but they can be managed with the help of your loved ones and support from experts. Engage with your family and friends and allow them to provide you with the care, love and support you need and deserve.
  • As a relative: Reflect on any possible signs of physical or cognitive decline when you visited older loved ones. Try to compare their current situation to their previous status and trust your instinct if anything seemed odd or worrying. Be open and talk to them calmly and supportively. Don’t be afraid to reach out to an expert who can help you, your loved one and your whole family identify and mitigate any issues. 
  • As an assisted living or nursing home owner / manager: Reflect on cases of residents who may have experienced difficulty with the holiday season schedule and activities. Talk to them about their experience and difficulties and reach out to their family if needed. Acknowledge the concerns of your residents’ relatives and listen to their feedback after visits. They know the personality and habits of a resident and can alert you if they feel something is concerning. Reach out to experts if needed. 
Senior man exercising next to a lake

Introduction

Constipation is a common problem in the elderly population. Epidemiological studies show that the incidence of constipation increases from the age of 65 by 25-50%. The frequency of constipation may be as high as 75% of patients who are in senior care facilities, hospitals or other institutions and in particular if they suffer from dementia, stroke, Parkinson’s disease or other degenerative neurological conditions. Constipation is also more common in patients taking medications that may affect bowel motility as discussed below.

Constipation is a problem that affects the quality of life, causes discomfort and many times significant concern that often results in several office visits, specialty referrals, hospital admissions, and surgical procedures. Constipation has therefore, a major impact on healthcare costs in the United States.

What is constipation?

The term constipation for everyone means different things. In general, it can mean a change in bowel habits, the production of hard stools, the production of small stools, difficulty in defecation, straining, reduced stool frequency, the feeling of incomplete evacuation, and so on. It is therefore very important to understand exactly what the patient is complaining about when he says that he suffers from constipation. Taking a detailed medical history is perhaps the most important factor in understanding and addressing the patient’s problem.

Medical history

As we explained earlier it is important to figure out what the term constipation means for the patient, to look for possible accompanying symptoms such as abdominal pain, bleeding, weight loss, discuss the patient’s diet, his medical treatment, his previous medical history, possible abdominal surgery in the past, etc.

The duration of the symptoms, any accompanying symptoms and other evidence from the medical history and physical examination will determine whether or not there is a need for laboratory, imaging examinations (e.g. CT scan) or endoscopic examinations (e.g. colonoscopy).

Causes of constipation

The causes of constipation are several and relate to problems of the bowel, but also other systems of the body, which can indirectly affect the intestine. In older people the causes of constipation are usually multifactorial. Trying to classify the causes of constipation, we can distinguish the following categories:

  • Obstructive causes: Colorectal cancer, narrowing of the bowel due to ischemia (poor blood circulation), inflammation of the bowel or external pressure from tumours and growths from neighbouring organs, etc.
  • Endocrine and Metabolic Causes: Diabetes, hypothyroidism (hypoactive thyroid), hypercalcaemia (high calcium in the blood), chronic kidney failure, etc.
  • Neuromuscular causes: Spinal cord injuries, Parkinson’s disease, multiple sclerosis, amyloidosis, scleroderma, myotonic dystrophy, etc.
  • Medicines: Opioids, antihypertensives, antidepressants, antiparkinsonian, antipsychotics, etc.
  • Other causes: diet low in fiber, dehydration, sedentary life, being bedridden, etc.

Management

The ways we deal with constipation depend on the severity of the symptoms, the causes, the accompanying diseases, and so on. Generally high fiber diet, hydration, daily regular toilet visit and exercise help the patient suffering from constipation. Many times, however, especially in the elderly, the above tactics do not help effectively or are not very practical. We therefore need to resort to some kind of pharmaceutical intervention for these patients. It is important to stress that the use of pharmaceuticals should be done with care and should be under medical supervision.

Categories of laxatives we use:

Stool bulking agents: The substances used contain natural or synthetic fiber in various forms. They are the first line of treatment for constipation and they work by increasing the volume of stools. Insoluble fiber has the tendency to cause gas and it is advisable to increase the dose gradually.

Osmotic laxatives: Osmotic laxatives consist of substances that are not absorbed by the digestive tract and thus remaining in the intestine retain a greater amount of water and as a result they soften the faeces.

Stimulant laxatives: These laxatives are based on senna or other synthetic substances and cause an increase in intestinal peristalsis (movement).

Fecal emollients / suppositories and enemas: This category is useful in cases where we suspect fecal impaction. They are usually combined with some oral laxatives for best results. Fecal impaction is more common in bedridden patients, neurological patients, people in nursing homes, and so on. These patients have a low sensitivity in the rectum, so they do not perceive the presence of stools. As stools accumulate in the rectum, they are dehydrated and cause paradoxical diarrea. This is confusing many times and delays the diagnosis which is established only with a rectal digital examination.

Summary

Patients aged over 65 often experience constipation, especially if they are suffering from neurological, metabolic or other systemic conditions, if they are taking certain medicines, are not being properly fed, or have reduced mobility. Good history and physical examination are often enough to assess the possible cause of constipation, but may sometimes require laboratory or other examinations to rule-out more serious conditions. Diet adaptation or simple pharmaceutical approaches are often enough to address the symptoms of constipation. However, there are cases where the severity or chronicity of constipation requires the help of a specialist.

Senior couple walking in the park

Depression is considered among the most disabling conditions affecting the quality of life of millions and contributing to increased mortality rate, especially in the elderly population where depression accounts for over 80% of deaths by suicide. Self-harm in adults over the age of 60 is found to be 67 times greater than the general population. Depression can lead to profound loss of function, mood changes, physical symptoms, altered thoughts and perception. Depression is considered an heterogenous group of disorders with overlapping core features including low mood, lack of interest and pleasure (anhedonia), fatigue and physical symptoms such as lack of appetite, sleeping disorders, hallucinations, motor symptoms etc.

Depression especially in the elderly can complicate other chronic organic disorders such as coronary artery disease, diabetes, kidney failure affecting their treatment by virtue of apathy, lack of engagement and compliance with the medications. It is also considered a risk factor for the development of coronary artery disease, stroke, colorectal cancer, irritable bowel syndrome and others. Depression in the elderly does not always manifest the same way as younger adults. The symptoms many times tend to be more severe and more physical as compared to the younger patients. 

Depression in the elderly many times is under-detected by their primary physician. Depression in later life is also far less likely to be treated than in younger adults. And even in cases where it is recognized, it is less likely to be referred to the psychiatric service. It is estimated that around one in six older depressed people in the UK receive treatment of any sort and only 6% is referred to the psychiatrist compared to 50% of young adults.

Studies vary regarding the real prevalence of depression in the elderly with reports varying from 0.4 to 35% with an average of 13.5% in ages over 55. There is a broader agreement regarding factors contributing to increased prevalence of depression. The important factors are being widowed and divorced, living in communities with poor social networks and low socioeconomic conditions. Interestingly enough, protective factors are having a religious faith, excercise, good physical health, being married and living within a strong social network. 

In terms of treating depression in the elderly we have to consider that it is a condition that can be self-limiting in a percentage of patients that can reach 30-40%. The principles of treatment in the elderly are the same as for young people. Treatment with antidepressants can reach a 60% response rate. The choise of the antidepressant medication has to be tailored to each individual taking into consideration the side effect profile of the drugs and co-morbidities of the elderly patient. Best outcomes are achieved when combining drugs with psychological therapies.

As depression tends to be so heterogenous, old and new therapies show varied results. It seems that an early response to therapy predicts better outcome. Following recovery it is important to carry on the therapy in the elderly as this strategy seems to lower the relapse rate. Approaches that minimize disability, promote independence, supportive therapies, and social networks play an important part of a treatment plan.