Lack of thirst, another neglect of dementia

On this occasion we bring you closer to a common situation in dementias such as the loss of the sensation of being thirsty. We do it with a double perspective: that of Wendy Mitchell, a 62-year-old woman from Yorkshire who has been living with a diagnosis of dementia for some time and who shares her experiences through her blog “Which me am I today?"; and that of Javier Alaba, a doctor in this house, with extensive experience in the care of people with dementia.

We leave you with the testimony of our friend Wendy....

The latest challenge dementia has thrown my way

I think I wrote about ‘not feeling hunger’ quite some time back. I’ve got used to that and it doesn’t bother me. I have my routine that means I eat, unless that routine is broken and then I might be running on empty until the routine kicks in the following day. But I’ve always been on the edge of whether I feel thirsty…..but again routine has kept me drinking my flasks of tea….I have two big flasks, one in the morning and one in the afternoon and I drink it because I love holding a cuppa tea, even on a hot summers day…..well, I think I do…. but shouldn’t the brain be telling me I’m thirsty?

It wasn’t really until my paraglide day that I realised dementia had taken away my ability to feel thirsty….that day I did the 10 mile walk around Derwentwater to scatter Sylvias ashes…and then had somehow climbed up Cat Bells before doing my paraglide and walking home….

Yes I was exhausted when I got back but then realised I’d done all that on one cuppa tea in the morning and another when I had a 30 minute break in my room before heading back to Cat Bells. I’d had my breakfast, so did have food inside me, but simply hadn’t noticed I hadn’t drunk much all day from 9am to 7pm when I got back.

It wasn’t actually until last week that I clicked with what was going on.

I went to Gemmas in the morning and Sarahs straight after to do her garden in her new house.  This meant I missed my routine of having a flask of tea during the morning. By pure chance me and Sarah tried one of the Chinese Tea balls that Suki Chan had sent me. I’d bought Sarah a see through tea pot just for the occasion and we christened it at her new house

It was several hours of hard work outside in the sun and I think Sarah said I’m going to have a drink, do you want one? I automatically said no and waited until I got home many hours later. Sarah didn’t question it because neither of us realised what was going on.

It’s so strange, the weird things dementia can do to you but it was then, when I got home and thought back,  it all fell into place and I realised I simply don’t feel thirsty any more.

I can’t even conjure up that sense of being hungry or feeling thirsty – it’s gone, vanished… when was the last time I felt thirsty ? 

So now it’s coming up with something that reminds me to drink even though I don’t feel like drinking, but to be aware of it, is the first stage…now I just have to remember…

Water is not just for summer

As Wendy says in her text, dementia is often accompanied by a series of challenges that are important to know in order to prevent them early, because once they appear it is more difficult to provide a solution.

Thirst depends on the balance of water and minerals, mainly sodium, in the body. As we age, our response becomes slower and more delayed, and we tend to become satiated earlier. This is due to alterations in body composition that lead to a decrease in the amount of intracellular water (more in women than in men) and muscle mass, as well as an increase in fatty tissue. In addition, we progressively lose our taste buds and visual acuity, making it difficult to drink water, especially if we take medications that dry out the mouth or leave a metallic taste. At the renal level, the cortical or external part becomes thinner, and at the functional level, vascularization, glomerular filtration, as well as the capacity to concentrate or dilute urine decreases, which makes the elderly person more at risk of dehydration in situations of volume loss and less capacity to retain sodium.

The need for fluids depends on the degree of activity, environmental conditions (temperature, humidity, altitude level), characteristics of the diet, habits such as smoking or alcohol, as well as certain diseases (diabetes, infections, neoplasms, liver, kidney or heart failure) and medications (diuretics, laxatives, opiates, psychotropic drugs).

In situations of dependency, knowledge and sensitization of caregivers is required to ensure adequate hydration, especially in the face of acute changes. It is easy to talk about exceeding two liters of water per day.

In people with dementia, in addition to the changes due to age, there are neuropathological alterations at the cerebral level; behavioral alterations, which sometimes lead to refusal of food; the presence of dysphagia with motor coordination problems especially when ingesting liquids that can lead to malnutrition, dehydration and choking; urinary incontinence with urine leakage and the need to go to the bathroom at night; alterations in bowel rhythm (with frequent constipation and diarrhea). And to all this should be added the usual presence of various diseases and certain medications that can interfere with the regulation mechanisms or increase fluid losses.

As for the symptoms of water or mineral loss, they are usually very vague, depending on the speed and intensity of the deficit, and take the form of dizziness, headache, nausea or drop in blood pressure. In an elderly person, and especially if he/she has dementia, it manifests in the form of changes in the level of attention, falls and instability, weakness, constipation, frequent symptoms in this population profile, so a high index of suspicion should be maintained.

There is no doubt about the importance of proper hydration in the health and well-being of these people. As the American writer Edward Abbey points out: "A great thirst is a great joy when it is quenched in time". The Decalogue that we leave you below includes recommendations to make this aspect an ally in the good care of those living with dementia.

1. Create guidelines for regular drinking. 

Make it easy for the person to always have some liquid on hand. Offer a glass at each meal, and another at mid-morning and mid-afternoon. Do not wait for the person to ask for it.

2. Encourage drinking before breakfast. 

Drinking a glass of water on an empty stomach prevents constipation, and a glass of orange juice at breakfast facilitates iron absorption in case of taking supplements.

3. Make drinking an appetezing activity.

Sweeteners/flavorings can be added to the water to give it a pleasant taste. As alternatives: juices, infusions, herbal teas, broths, jellies, coffee...

4. Increase the consumption of fruits with a high water content: watermelon, melon, peach...

5. Increase fluid intake in cases of increased ambient temperature or fever, increased respiratory rate, fluid loss or hyperglycemia.

6. In the event of a decrease in the level of attention, check the level of hydration and review medications. 

Be sure to consult your doctor.

7. Avoid low-salt diets, except in cases of severe hypertension, advanced cardiac or renal failure, and severe edema.

8. Take care to mantain an adequate oral hygiene, especially in people under treatment with thickeners or gelatines. In cases of dry mouth, artificial saliva can be used.

9. Calculate the need of liquids and pour them in containers that allow to know their consumption in a simple way. Check the water temperature. It is recommended from 12 to 14ºC.

10.  In case of urinary incontinence or the need to urinate frequently at night, reduce fluid intake after snack, ensuring adequate hydration throughout the rest of the day.