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Elderly patients often are at higher risk than the general population for dehydration, a condition in which the body contains less body fluid than it should for normal function. There is a host of underlying conditions that can cause dehydration, and physical therapy is one of them; when therapists ask patients to exercise, the body’s fluid ratio may shift out of balance.

According to John Rabbia, PT, GCS, of Baldwinsville, N.Y., many believe the true incidence of dehydration in older people is underreported because the symptoms can be so easily masked or mimic other conditions. According to Rabbia, people age 85 to 99 are six times more likely to be hospitalized for dehydration than those 65 to 69, and, of those hospitalized, 18% will die within 30 days.

Common Culprits

Older people are at higher risk for having partially blocked arteries and poor perfusion, which elevates their risk for dehydration, says William Greenough, MD, geriatrician, professor of medicine, and professor of international health at Johns Hopkins University in Baltimore.

Dehydration also is commonly the result of diarrheal diseases, he says. Especially among the elderly, people might take a remedy for the diarrhea but not realize the potential for dehydration and their need to replace lost fluid with Pedialyte or Ceralyte, a rice-based solution. The key, according to Greenough, is for seniors to drink enough of the solution so they maintain good urine output and don’t feel lightheaded or dizzy when they stand.

But physical therapy can exacerbate the problem when patients have to exercise. “You need a normal circulating blood volume when you’re trying to do PT. It is a common problem that we see here: When someone is dehydrated, they go to PT and their blood pressure drops,” Greenough says. “[In this case,] we would replace fluid before the person goes to therapy or even when someone is in therapy.”

Rabbia cautions, “Physical therapists should be aware that any patient with impaired hand dexterity or body control, swallowing problems, [or] impaired communication or comprehension is at increased risk for dehydration. Other conditions that predispose a patient to dehydration include use of diuretics, abuse of laxatives, uncontrolled diabetes, enteral feedings, imposed fluid restrictions, highly draining wounds, or even a history of dehydration.”

Cause for Concern

PTs should look for drops in blood pressure and complaints of feeling faint, lightheaded, and weak. They should consider asking patients at highest risk for dehydration about their urine output, Greenough says.

Rabbia says the early signs of dehydration, such as increased thirst and dry mouth, are easy to miss because they are subtle. People suffering from moderate dehydration often complain of lightheadedness or muscle cramps, or they may act irritable or restless. A rapid heart rate and arms and legs that are cool to the touch are other common symptoms of moderate dehydration. Symptoms of severe dehydration include altered behavior; anxiety; confusion; an inability to stand or walk; rapid respiratory rate; cold, clammy, or hot, dry skin; and in the most severe cases, loss of consciousness.

“Many of the symptoms of dehydration include physical manifestations that physical therapists can recognize during treatment. If an older patient is having more difficulty than usual following directions or maintaining attention, dehydration should be considered as a contributing factor,” Rabbia says.

Brian Lupus, PT, clinical coordinator at Johns Hopkins Bayview Medical Center in Baltimore, says that even subtle changes in a patient’s thought process should be a warning to PTs, especially those who work in the acute hospital setting.

Preventing Dehydration

Awareness of the problem is the first step. Greenough recommends that PTs make sure patients are adequately hydrated: “To do that, you have to know what has been lost. In the summer, in older people, sweating is a major cause of it,” he says. Having an air-conditioned facility will reduce sweating during the therapy session, but PTs should recognize that patients might have become overheated before entering the clinic. Having Gatorade on hand, as well as Pedialyte or Ceralyte solution, is useful because it helps to replace fluids lost from sweating.

The concept regarding dehydration is simple, according to Greenough: You need to replace what is lost in both volume and composition. So, giving a patient plenty of water not only misses the composition boat, but also causes water intoxication. “If you lose salt and water from the body through diarrhea and sweat and you give back water, you’ll get water intoxication, which causes seizures and sometimes death,” Greenough says. It’s also important to be aware of the medications that patients might be taking — medications that might deplete them, Lupus says: “If they just took their [diuretics] a few hours before [PT], that they may need [fluid] replacement.

So, make sure you’re hydrating, without over-hydrating.” If a patient becomes weak or faint and the PT suspects dehydration, Greenough recommends instructing the patient to sit and giving the person an oral hydration solution. He prefers Ceralyte to Pedialyte, because, he says, the rice-based formula tastes better and is absorbed faster. “In about 20 or 30 minutes, these patients are usually fine,” he says.

Although dehydration is a serious and potentially lethal condition, it is easily prevented and treated in its mild and moderate stages, Rabbia says: “Physical therapists need only maintain an awareness of the risk factors for dehydration and encourage patients to maintain a healthy fluid intake to prevent this avoidable condition.” l