Increasing Fluid Intake and Reducing Dehydration Risk in Older People Living in Long-Term Care: A Systematic Review
Open accessAbstract
OBJECTIVE: To assess the efficacy of interventions and environmental factors on increasing fluid intake or reducing dehydration risk in older people living in long-term care facilities. DESIGN: Systematic review of intervention and observational studies. DATA SOURCES: Thirteen electronic databases were searched from inception until September 2013 in all languages. References of included papers and reviews were checked. ELIGIBILITY CRITERIA: Intervention and observational studies investigating modifiable factors to increase fluid intake and/or reduce dehydration risk in older people (≥65 years) living in long-term care facilities who could drink orally. REVIEW METHODS: Two reviewers independently screened, selected, abstracted data, and assessed risk of bias from included studies; narrative synthesis was performed. RESULTS: A total of 4328 titles and abstracts were identified, 325 full-text articles were obtained and 23 were included in the review. Nineteen intervention and 4 observational studies from 7 countries investigated factors at the resident, institutional, or policy level. Overall, the studies were at high risk of bias due to selection and attrition bias and lack of valid outcome measures of fluid intake and dehydration assessment. Reported findings from 6 of the 9 intervention studies investigating the effect of multicomponent strategies on fluid intake or dehydration described a positive effect. Components included greater choice and availability of beverages, increased staff awareness, and increased staff assistance with drinking and toileting. Implementation of the US Resident Assessment Instrument reduced dehydration prevalence from 3% to 1%, P = .01. Two smaller studies reported positive effects: one on fluid intake in 9 men with Alzheimer disease using high-contrast red cups, the other involved supplementing 13 mildly dehydrated residents with oral hydration solution over 5 days to reduce dehydration. Modifications to the dining environment, advice to residents, presentation of beverages, and mode of delivery (straw vs beaker; prethickened drinks vs those thickened at the bedside) were inconclusive. Two large observational studies with good internal validity investigated effects of ownership; in Canada, for-profit ownership was associated with increased hospital admissions for dehydration; no difference was seen in dehydration prevalence between US for-profit and not-for-profit homes, although chain facilities were associated with lower odds of dehydration. This US study did not suggest any effect of staffing levels on dehydration prevalence. CONCLUSIONS: A wide range of interventions and exposures were identified, but the efficacy of many strategies remains unproven due to the high risk of bias present in many studies. Reducing dehydration prevalence in long-term care facilities is likely to require multiple strategies involving policymakers, management, and care staff, but these require further investigation using more robust study methodologies. The review protocol was registered with the International Prospective Register of Systematic Reviews (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42012003100).
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Most trials aiming to increase fluid intake in older adults assessed fluid intake, hydration status and health outcomes poorly, so success in increasing fluid intake is unclear.
“Unfortunately, most trials assessed fluid intake hydration status and health outcomes poorly, so success in increasing fluid intake is unclear.”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [220]
The Discussion (page unavailable) says most studies had considerable risk of bias and that, without 24-hour measurement, a change in overall fluid intake cannot be determined. The Risk of Bias section (page unavailable) finds fluid-intake or hydration assessment at high risk of bias in 16 of 23 studies. The copy supports uncertainty about increasing fluid intake, but does not specifically establish that most trials assessed health outcomes poorly. (LLM, conf=0.84)
Experimental — accuracy not yet measuredThe introduction of the US Resident Assessment Instrument (which requires mandatory monitoring and reporting of hydration risks) reduced dehydration in older adults.
“It was also suggested that the introduction of the US Resident Assessment Instrument (which requires mandatory monitoring and reporting of hydration risks) reduced dehydration in older adults(220, 261).”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [220]
The RAI-MDS section (page unavailable) reports that dehydration prevalence in US nursing-home residents fell from 3% to 1% after compulsory implementation, supporting the suggested reduction. It does not say that the instrument requires mandatory monitoring and reporting of hydration risks, and the finding is specific to long-term-care residents rather than older adults generally. (LLM, conf=0.86)
Experimental — accuracy not yet measuredA recent systematic review suggested that multiple strategies including involvement and input from older adults, staff, management, and policymakers will be needed to address problems with drinking in residential care.
“A recent systematic review (see recommendations 67, 68) suggested that multiple strategies including involvement and input from older adults, staff, management, and policymakers will be needed to address problems with drinking in residential care (220).”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [220]
The Abstract says reducing dehydration in long-term care is likely to require multiple strategies involving policymakers, management, and care staff. The Conclusion calls for work at resident, institutional, and policy levels and for person-centered approaches to drinking barriers, but it does not specifically call for older adults’ involvement and input. (LLM, conf=0.83)
Experimental — accuracy not yet measuredMulti-component strategies across institutions to support adequate drinks intake have been clearly shown to prevent or treat low-intake dehydration in older adults.
“multi-component strategies across their institutions for support adequate drinks intake have been clearly shown to prevent or treat low-intake dehydration in older adults.”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [220]
The Discussion reports that 6 of 9 multicomponent interventions showed a trend toward increased fluid intake. But the Discussion and Conclusion caution that high risk of bias left the effectiveness of many strategies unproven; the review does not establish that these strategies clearly prevent or treat low-intake dehydration. (LLM, conf=0.89)
Experimental — accuracy not yet measuredIn Canada, for-profit care home ownership was associated with increased hospital admissions for dehydration.
“in Canada for-profit ownership was associated with increased hospital admissions for dehydration”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [220]
A small single study implied that high contrast red cups helped support drinking in nine men with dementia.
“A small single study implied that high contrast red cups helped support drinking in nine men with dementia (220).”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [220]
The review identified 19 intervention and four observational studies from seven countries.
“The review identified 19 intervention and four observational studies from seven countries”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [220]
In the US, dehydration prevalence did not differ between for-profit and not-for-profit care homes.
“in the US dehydration prevalence did not differ between for-profit and not-for-profit homes (220).”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [220]
The systematic review described before/in recommendation 62 suggests that multicomponent interventions including increased staff awareness, assistance with drinking, support using the toilet and a greater variety of drinks on offer may be effective.
“The systematic review described before/in recommendation 62 suggests that multicomponent interventions including increased staff awareness, assistance with drinking, support using the toilet and a greater variety of drinks on offer may be effective (220).”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [220]
The evidence suggests that multicomponent interventions may be effective.
“The evidence suggests that multicomponent interventions may be effective (220).”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [220]
The review suggested that overall the studies were at high risk of bias.
“but suggested that overall the studies were at high risk of bias.”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [220]
No clear relationships were observed between staffing levels and dehydration prevalence.
“No clear relationships were observed between staffing levels and dehydration prevalence(220, 262, 263).”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [220]
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- Authors
- Bunn, D., Jimoh, F., Wilsher, S. H., & Hooper, L.
- Affiliations
- University of East Anglia (GB)
- Corresponding author
- Bunn, Diane
- Venue
- Journal of the American Medical Directors Association
- Publisher
- Elsevier BV
- Published
- 2015-02
- Volume
- 16
- Issue
- 2
- Pages
- 101-113
- ISSN
- 1525-8610 (ISSN-L)
- OpenAlex
- W1965597588
- Cited by
- 115
- References
- 42
- Citations by year
- 2026: 7 · 2025: 8 · 2024: 9 · 2023: 5 · 2022: 6 · 2021: 14 · 2020: 11 · 2019: 16 · 2018: 12 · 2017: 6 · 2016: 13 · 2015: 7 · 2014: 1
- FWCI
- 1.53
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Journal of the American Medical Directors Association (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- UEA Digital Repository (University of East Anglia) (submittedVersion, cc-by-nc-nd)
- Funders
- National Institute for Health and Care Research (CDF-2011-04-025)
- Topics
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Health Sciences › Health Professions › Speech and Hearing › Dysphagia Assessment and Management
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Keywords
- dehydration, fluid intake, older adults, long-term care facilities, nursing homes, multicomponent intervention, Resident Assessment Instrument, facility ownership, staffing levels, hospitalization, Alzheimer's disease, quality of care, risk of bias, eating environment, employee awareness
- MeSH terms
- Aged, Aged, 80 and over, Aging, Dehydration, Drinking, Female, Homes for the Aged, Humans, Long-Term Care, Male, Nursing Homes, Ontario, Residential Facilities, Geriatric Assessment, Risk Assessment, Risk Reduction Behavior
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