Increasing fluid intake and reducing dehydration risk in older people living in long-term care: a systematic review

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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: 4328 titles and abstracts were identified, 325 full-text papers obtained and 23 included in the review. Nineteen intervention and 4 observational studies from 7 countries investigated factors at 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 six of the nine intervention studies investigating the effect of multi-component strategies on fluid intake or dehydration described a positive effect. Components included greater choice and availability of beverages, increased staff awareness, increased staff assistance with drinking and toileting.

Implementation of the US Resident Assessment Instrument reduced dehydration prevalence from 3% to 1%, p=0.01. Two smaller studies reported positive effects, one on fluid intake in 9 men with Alzheimer's 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; pre-thickened 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.

Systematic review registration: The review protocol was registered with the International Prospective Register of Systematic Reviews
( ID=CRD42012003100).
Original languageEnglish
Pages (from-to)101-113
Number of pages13
JournalJournal of the American Medical Directors Association
Issue number2
Early online date12 Dec 2014
Publication statusPublished - 1 Feb 2015


  • Aged
  • Long-Term Care
  • geriatrics
  • Drinking
  • dehydration
  • Beverages

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