For About and By Caregivers

Hydration and Delirium

By Catherine D’Aniello, MSN, RN


Did you know that:

  • Delirium is different from dementia?

  • Dehydration is a cause of delirium?

  • Older adults can avoid delirium by staying hydrated?

Delirium is a mental disturbance characterized by new or worsening confusion, changes in level of consciousness or hallucinations. Delirium is different from the slow progression of dementia or Alzheimer’s disease. It has a sudden onset from hours to days and although delirium can be reversed, it is easier to prevent than cure.

All “elderly” adults (people over 65 years old) are at risk for delirium due to factors involving their own internal weakness and environmental insults. Some risk factors, such as advanced age or having dementia, are fixed. Other risk factors such as pain, malnutrition, dehydration, sensory loss, depression and fever are modifiable with intervention. With each factor present, delirium risk increases. Therefore, the key to preventing delirium is reducing the number of modifiable risk factors.

Infection and dehydration are common modifiable delirium risk factors. Older adults usually know when they have an infection, but do not recognize when they are dehydrated.

Mental status changes begin with mild dehydration and worsen with each stage, ending in delirium. In moderate dehydration, short-term memory loss occurs.

Once an older person is thirsty, they are already mildly dehydrated. Symptoms of severe dehydration include dry mouth and lips, sunken eyes, increased mental status changes and decreased urine output. This is a medical emergency which results in delirium and if not reversed, death ensues.

Failure to recognize signs of dehydration predisposes older adults to becoming increasingly and chronically dehydrated, which is a slippery slope towards delirium. Closing this knowledge gap will reduce delirium risk because inadequate fluid intake is relatively easy to remedy.

Why are older adults prone to dehydration?

Generationally, older adults are not focused on hydration. Many seniors purposely limit fluid intake because they fear bladder accidents. Others with compromised mobility may curb fluid intake to avoid extra bathroom trips. Poor access to fluids or needing help to drink may limit intake. Many drink water only when taking medication. Living in over-heated indoor spaces dehydrates even without sweating.

Older adults have decreased muscle mass and increased fat; because 75 percent of body water is stored in muscle, seniors have less capacity to store water.  Women have more body fat than men at any age, so older women are at even higher risk of dehydration. Due to decreased kidney function, older adults cannot conserve fluids as well as younger people. 

How do you know if you are drinking enough?

An older adult, their home caregiver or family member can take simple steps daily to check hydration status. First, thirst should not be experienced at any time. Second, urine should be colorless or straw colored, and odorless. Being familiar with a urine color chart is good practice for all ages and critical for older adults to avoid dehydration. First morning urine should not be dark, and urination should occur every two to four hours during waking hours. Some medications and foods such as asparagus give urine an odor, but normally urine should not smell.

Increase daily fluid intake, especially water!

At least half of your daily fluids should be water. Water significantly reduces older adults’ risk of becoming delirious. Milk, vegetable or fruit juice, and soup are also healthy fluid choices. Carbonated and caffeinated drinks should be limited due to their diuretic effect. The body needs water to filter alcoholic beverages from the body. Therefore, increased water consumption is needed overall as well as to balance the dehydrating effects of unhealthy drinks. Drinking healthy fluids is as important as eating healthy foods. 

Family members and home caregivers should:

  • Educate older adults on dehydration risks

  • Encourage/remind seniors to drink

  • Teach loved ones not to wait to feel thirsty to drink

  • Teach loved ones to drink regularly throughout the day

  • Make fluids easily accessible 

  • Serve fluids at a temperature the individual prefers

  • Encourage water with ALL meals

  • Boost the flavor of water by adding drops of lemon/ lime juice

  • Limit fluid intake one to three hours before bed

  • Offer popsicles, juice, gelatin, Italian ice, sherbet and pudding
    to those who dislike water. 

Increased awareness of dehydration as a cause of confusion and delirium should begin when older adults are “young-old” (65-74 years) in order to form healthy drinking habits carrying them into “middle-old” (75-84 years) and “old-old” (85 years and above). Family should report poor eating or drinking to the primary care provider so interventions can be initiated to prevent dehydration and its consequences. Educate your older family members and their caregivers on the importance of hydration and ways to facilitate good fluid intake.

Why not reduce your or an older loved one’s chance of developing delirium by eliminating the dehydration risk factor?

Catherine D’Aniello holds a BSN from University of Connecticut and MSN from University of Hartford. She has 30 years of geriatric experience and is currently a Resident Care Coordinator at a skilled nursing facility.


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