As we age or progress through severe illness, some of the biggest issues we face often turn out to be some of the most basic: staying hydrated and maintaining proper nutrition. Many medical concerns stem from a lack of proper hydration or inadequate intake of essential nutrients needed to sustain basic bodily functions. These issues are often exacerbated by illness and can become a major problem when a patient enters hospice care. 

Patients who have a serious or terminal illness often lose their appetites or thirst responses, forget to eat or drink, or, due to the illness or medicinal side effects, lose nutrients and water at a more rapid pace. This can lead to weight loss and severe dehydration, which can affect bodily functions and internal organs, worsening  illnesses and quality of life.

It is extremely important that caregivers and hospice care teams keep track of a patient’s diet and water intake, recognize the signs of dehydration and malnutrition, and take steps to stimulate the appetite and/or keep patients hydrated throughout the day. 

Why is malnutrition and dehydration so common in the elderly and hospice patients?

First, let’s define these terms. According to the Cleveland Clinic:

Malnutrition is an imbalance between the nutrients your body needs to function and the nutrients it gets. This can mean undernutrition or overnutrition. You can be malnourished from an overall lack of calories, or you might have a protein, vitamin, or mineral deficiency. You might also have excess calories – more than your body knows what to do with.

Dehydration is the absence of enough water in your body. The best way to beat it is to drink before you get thirsty. If you feel thirsty, you are already mildly dehydrated, which can cause symptoms such as headache, fatigue, and dizziness. Dehydration, in extreme cases, can contribute to life-threatening illnesses like heatstroke. 

There are several factors that cause the elderly and hospice patients to be more susceptible to malnutrition and dehydration. These can be categorized as physiological, psychological, and pharmacological. 

Physiological

Physiological factors are mostly due to natural changes in our bodies as we age or progress through an illness. As you get older, your appetite and thirst tend to diminish. This means that while your body may be craving food or water, you may not notice it and, as a result, eat or drink  less than you need to stay healthy. According to a study from UCLA’s school of nursing, up to 40% of elderly people are chronically under-hydrated, and another study showed between 15%-40% of the elderly suffer from a decrease in appetite — with higher rates in women and nursing home residents. Appetites may also decline acutely in response to illness. In addition, our body compositions change, which affects the digestive system, sense of smell and taste, saliva production, and hormones. Also, our kidneys become less efficient, so we lose more water during urination. 

Psychological

Appetite and thirst are strongly influenced by environment and mood. This means many of the psychological changes that can occur with aging or illness can influence appetite and thirst. Mood disorders such as depression are known to impair appetites and are common in patients with terminal illness and the elderly. Patients with dementia or Alzheimer’s can also have a reduced appetite, which can lead to malnourishment and dehydration. Additionally, living and eating alone can cause a reduced appetite, possibly due to a lack of assistance with cooking and shopping, and because there are fewer social cues to eat. Portion sizing can also affect a patient’s appetite or fluid intake. If the portions or drinks are too large, then a patient may be less inclined to consume.

Pharmacological

Hospice patients and the elderly are more likely to take medications, and medication side effects often affect appetite and thirst, putting them at a higher risk of malnourishment and dehydration. Medications may cause something as small as a reduction in saliva production, which can lead to poor oral health, diminishing the sense of taste. If a patient has a reduced sense of taste, they may be less inclined to eat or drink throughout the day. Medications may also change hormone levels involved in appetite control and affect the way the body processes water, which can cause dehydration.

What are the symptoms of malnourishment and dehydration?

When caring for a patient, it’s crucial that hospice care teams and caregivers recognize the  symptoms of malnutrition and dehydration as soon as possible to maintain the best quality of life. 

Symptoms of Dehydration

It is important to be aware of the common signs of dehydration so treatment can be administered. Dehydration can cause urinary tract infections, heat stroke, heart and kidney issues, and blood clotting issues. It can also cause hypovolemia or hypovolemic shock, the state of abnormally low extracellular fluid in the body due to loss of fluids such as salt and water or blood. This is often a result of excessive vomiting or diarrhea (side effects of dehydration), and can cause the organs to stop functioning properly. 

If the patient has underlying health conditions like COPD, heart failure, kidney disease, or diabetes, it is very important to talk to the patient’s physician and care team regarding the amount of fluids the patient needs to stay hydrated. A rule of thumb is that a patient should take one-third of their body weight and drink that number of ounces, but each patient is different and should consult their care team.

Common symptoms of dehydration include:

  • Dark-colored urine, urinating less frequently
  • Fatigue or weakness
  • Irritability
  • Dizziness
  • Headaches
  • Muscle cramps in the arms and legs
  • Dry mouth
  • Confusion or decreased cognitive function
  • Dry skin
  • Lack of coordination, which can lead to falls and injury

If dehydration is serious, immediate attention is required. Anyone suffering from these symptoms should go to the emergency room right away. Symptoms of serious dehydration include:

  • Rapid heart rate
  • Trouble moving or walking
  • Confusion or disorientation
  • Fainting and/or vomiting or diarrhea that lasts longer than 24 hours

Symptoms of Malnutrition

Malnutrition and reduction in appetite can increase the risk of falls, osteoporosis, fractures, and muscle weakness, along with a decrease in wound healing, immune function, and overall quality of life. It can be difficult to recognize symptoms right away, as they can correlate to the patient’s illness diagnosis, but caregivers should make themselves aware of all symptoms so they can catch issues early and have them treated.

Common symptoms of malnutrition include:

  • Sudden or unintentional weight gain or weight loss
  • Swelling, especially in the hands, face, and feet
  • Food aversions or complaints about the taste or smell of food
  • Exhibited loss of appetite or interest in food
  • Frequent coughing, gagging, or choking while eating
  • Lack of energy
  • Little to no movement in a day-to-day routine
  • Weak immune system
  • Infrequent bowel movements
  • Low mood, sadness, depression

How to stimulate appetite and increase hydration in the elderly and hospice patients

Understanding how to stimulate appetite and increase hydration for patients in hospice care will help avoid serious problems. The first and most important step is to  identify and treat any underlying causes, without which any measures implemented will be unsuccessful. 

Stimulating appetite

There are a few small things that caregivers and hospice care teams can do to stimulate the patient’s appetite and get them eating again. These steps include:

  • Cutting food into smaller pieces or offering small portions
  • Offering more visually appealing foods
  • Creating a meal schedule routine so the patient’s body becomes used to the timing of eating
  • Offering smaller snacks more often throughout the day
  • Blending or mashing foods so they don’t need to be chewed as much
  • Offering soft and smooth foods such as soup, yogurt, applesauce, or pudding
  • Offering shakes or smoothies
  • If the patient has nausea, try giving them dry, salty foods and clear liquids
  • If the patient has digestive issues, offer them fruit such as prunes, have them move around if possible, and talk with the care team about the use of laxatives or stool softeners

Increasing hydration

Making sure a patient is hydrated doesn’t just include drinking fluids throughout the day. The patient can also get hydration through fruits and vegetables high in water content. Here are some small steps to increase hydration:

  • Give them small drinks more often throughout the day — water, milk, sparkling water, or low-sugar fruit juices
  • Offer more fluids during meal times
  • Provide water-heavy foods such as watermelon, cucumbers, celery, strawberries, or low-sodium broths and soups
  • Avoid hot or humid conditions to reduce sweating, which can dehydrate the patient
  • Keep water close by the patient so it’s easier for them to access

Taking these small steps and implementing them into a patient’s daily routine can be a great way to ensure they stay hydrated and nourished. It can help avoid serious conditions that can exacerbate any illnesses or conditions from which the patient is already suffering. Caregivers should speak with the hospice care team about any medications that can cause dehydration or malnourishment, and take specific steps to support the patient in these ways.