Continuing Education Activity

Dehydration in adults is a critical clinical condition resulting from an imbalance between fluid intake and losses, leading to electrolyte disturbances and potential multiple organ dysfunction. Adult dehydration can manifest with a wide range of symptoms—from mild thirst and weakness to severe issues, such as hypovolemic shock and neurological impairment. Dehydration is especially dangerous for vulnerable populations, including older adults, critically ill patients, and individuals with chronic medical conditions. Understanding the underlying causes, recognizing early warning signs, and implementing timely interventions are essential for preventing severe complications and improving patient outcomes.

The condition often results from low fluid intake, increased fluid loss, or both, and is influenced by aging and medications. Diagnosis relies on laboratory tests, with treatment focusing on fluid replacement and addressing the underlying causes. Early recognition and timely intervention are essential for preventing complications and improving outcomes. This activity provides an in-depth review of adult dehydration, covering its etiology, pathophysiology, clinical presentation, diagnostic evaluation, and both medical and supportive treatment strategies. This activity also emphasizes evidence-based practices for effective fluid management while exploring best practices and prevention strategies. Additionally, this activity highlights the importance of interprofessional collaboration among healthcare providers and patient-centered care, offering valuable insights and practical tools to enhance patient safety, optimize clinical workflows, and improve healthcare outcomes.

Objectives:

• Identify the signs and symptoms of dehydration in adults, including those specific to vulnerable populations such as older adults and critically ill patients.
• Implement standardized hydration protocols and evidence-based fluid management strategies to optimize hydration therapy in adult patients.
• Select the most appropriate fluid replacement methods (oral rehydration or intravenous fluids) based on the severity of dehydration and the patient’s condition.
• Collaborate with interdisciplinary healthcare teams, including dietitians, nurses, and pharmacists, to develop comprehensive care plans for dehydration management.

Introduction

Dehydration in adults is a clinically significant condition caused by an imbalance between fluid intake and loss, often leading to disturbances in the balance of total body electrolytes. Although mainstream media frequently claims that 75% of Americans are chronically dehydrated, no scientific evidence in the medical literature supports this assertion. In contrast, dehydration is highly prevalent among older adults, with reported prevalence rates in the United States ranging from 17% to 28%.[1] 

Dehydration is often precipitated by low fluid intake, increased fluid loss, or a combination of both of these factors. This is further influenced by factors such as age-related changes, chronic illness, and medication use.[2] The pathophysiological mechanisms include activation of the renin-angiotensin-aldosterone system, increased release of antidiuretic hormone (ADH), and stimulation of the sympathetic nervous system, all of which work to retain fluids and stabilize circulation.

Clinically, dehydration presents with symptoms ranging from mild thirst and fatigue to severe complications such as confusion, hypotension, and multiple organ dysfunction.[3] Dehydration is a common cause of hospital admissions, contributing to significant morbidity and mortality while often complicating a range of medical conditions.[2] Dehydration is primarily diagnosed clinically, with laboratory investigations, including serum electrolytes, serum osmolality, and renal function tests, providing supportive information. Treatment focuses on correcting fluid and electrolyte imbalances through oral or intravenous (IV) rehydration while closely monitoring serum electrolytes and renal function.[4] 

Fortunately, dehydration is both preventable and treatable. Preventive measures, such as maintaining adequate fluid intake, regularly monitoring at-risk populations, and providing patient education—especially for older adults—are crucial for reducing its incidence and complications. A thorough understanding of dehydration’s causes, clinical signs, and diagnostic criteria can enhance patient care by ensuring early recognition, timely intervention, and the prevention of severe complications.

Etiology

Body water is lost through the skin, lungs, kidneys, and gastrointestinal tract. Dehydration occurs when water loss exceeds replacement and may result from the loss of water without sodium. This condition often arises from the failure to replace obligatory water loss. Multiple factors contribute to dehydration (see Table 1).[1]

Table

Table 1. Causes of Dehydration.

Epidemiology

Dehydration is a common condition in adults, particularly among vulnerable populations such as older adults and those with chronic diseases. The incidence of dehydration varies depending on the definition, diagnostic criteria, and population studied. However, epidemiological data indicate that dehydration is a significant contributor to global hospital admissions and poor health outcomes.[5] Older individuals are 20% to 30% more prone to developing dehydration due to factors such as immobility, impaired thirst mechanism, diabetes, renal disease, and polypharmacy.[6][7]Prevalence and Risk Factors

Dehydration can affect individuals of all ages, but older adults are disproportionately impacted due to physiological changes, reduced thirst sensation, and a higher prevalence of comorbid conditions. Older individuals in institutionalized settings face even greater risks, with factors such as diminished cognition and dependence on caregivers for fluid intake, compounded by environmental issues like inadequate access to fluids.[8]Poor fluid intake is one of the most common causes of dehydration in adults, often influenced by factors such as mobility limitations, cognitive impairment, and social determinants of health. Chronic medical conditions, including diabetes mellitus, renal disease, and gastrointestinal disorders, contribute to dehydration by increasing fluid loss or impairing fluid retention mechanisms. Medication use, particularly diuretics, laxatives, and certain classes of antihypertensive drugs, is also a significant risk factor for dehydration in adults.[9]

Hospitalization and Mortality Rates

Dehydration is one of the leading causes of hospitalization, accounting for approximately 1% to 3% of all hospital admissions in the United States. However, this condition is higher during extreme weather events such as heat waves.[10] Research shows that dehydration is associated with longer hospital stays, higher healthcare costs, and increased morbidity and mortality rates. Severe dehydration can lead to life-threatening complications, including acute kidney injury (AKI), electrolyte imbalances, and cognitive impairment, particularly in older adults and those with underlying chronic conditions.[11]In community-dwelling adults, dehydration increases the risk of falls, urinary tract infections (UTIs), and cognitive decline.[2] Mortality rates in hospitalized patients range around 15%, depending on the severity of dehydration and the presence of comorbid conditions.[12][13] Dehydration is also a leading cause of readmissions among older adults, highlighting the need for more effective prevention and post-discharge monitoring strategies.[14]Geographic and Seasonal Variability

The incidence of dehydration varies geographically, with higher rates reported in regions with extreme temperatures, limited access to clean water, and high rates of infectious diseases contributing to fluid loss. Seasonal variations also impact dehydration rates, with increased hospitalizations observed during the summer months due to elevated perspiration and inadequate fluid replacement.[15][16]] Individuals in professions with prolonged exposure to high temperatures, such as construction workers and outdoor laborers, are also at increased risk of dehydration.

Pathophysiology

Water is essential for maintaining various physiological functions in the body. The human body is composed of 55% to 65% water, with two-thirds found intracellularly and one-third in the extracellular space. Of the extracellular water, one-fifth is found in the intravascular space.[17][18] The body depends on a complex system to maintain euvolemia, which refers to the stable and normal volume of blood and extracellular fluid.

Dehydration occurs when fluid loss exceeds intake, leading to a reduction in total body water, which results in clinical abnormalities in thermoregulation, skin elasticity, and circulatory stability. The most common underlying causes of dehydration include impaired thirst mechanisms, reduced renal concentrating ability, and an increased risk of fluid loss due to illness or environmental factors.

Physiological Mechanisms of Dehydration

The body has several homeostatic mechanisms to counteract dehydration and maintain euvolemia:

• Thirst mechanism and hypothalamic regulation: Osmoreceptors in the hypothalamus trigger the thirst response and promote water intake when plasma osmolality increases. However, this mechanism is less sensitive in older adults, making them more prone to dehydration.[19]

• Antidiuretic hormone and renal water retention: When plasma osmolality increases, the posterior pituitary gland secretes ADH, also known as vasopressin, which increases water reabsorption in the renal collecting ducts. This process reduces urine output and helps conserve water, which is essential for maintaining blood pressure and preventing hypovolemia. Please see StatPearls' companion resource, "Physiology, Vasopressin," for more information. 

• Renin-angiotensin-aldosterone system activation: When intravascular volume is low, the kidneys release renin, which converts angiotensinogen into angiotensin I. The angiotensin-converting enzyme (ACE) then converts angiotensin I to angiotensin II. Angiotensin II stimulates aldosterone release from the adrenal glands, promoting sodium and water retention. Angiotensin II also causes vasoconstriction, which helps maintain blood pressure during dehydration. Please see StatPearls' companion resource, "Physiology, Renin Angiotensin System," for more information.

Types of Dehydration and their Pathophysiological Effects

Dehydration is categorized based on the relative loss of water and sodium, each with distinct pathophysiological effects.

• Isotonic dehydration: This occurs when water and sodium are lost equally, as seen in conditions like vomiting, diarrhea, and hemorrhage. This leads to hypovolemia or reduced plasma volume, manifesting as tachycardia, hypotension, and diminished organ perfusion.[17]

• Hypertonic dehydration: This occurs when water loss exceeds sodium loss, resulting in hypernatremia. Common causes include inadequate fluid intake, excessive sweating, and diabetes insipidus. The resulting cellular dehydration can lead to neurological symptoms such as confusion, seizures, and coma.[20]

• Hypotonic dehydration: This occurs when sodium loss exceeds water loss, resulting in hyponatremia. It is commonly seen in individuals using diuretics or those with chronic kidney disease (CKD) or adrenal insufficiency. The resulting fluid shift into cells can lead to cerebral edema, muscle weakness, and lethargy.[17] 

Systemic Effects of Dehydration

Dehydration involves multiple organ systems, leading to significant physiological consequences, as mentioned below.[14]

• Cardiovascular effects: Hypovolemia decreases cardiac output, which stimulates tachycardia and hypotension. In severe cases, shock and multiple organ failure may occur. 

• Neurological effects: Hypertonic dehydration induces an osmotic shift, leading to the shrinkage of brain cells, which can cause delirium, confusion, and seizures. In contrast, hypotonic dehydration results in cerebral edema, raising intracranial pressure and increasing the risk of brain herniation.

• Renal effects: Reduced renal perfusion can lead to AKI, presenting with oliguria or anuria. Prolonged dehydration increases the risk of nephrolithiasis (kidney stones) and may contribute to the development of CKD.

• Gastrointestinal effects: Hypoperfusion of the gut mucosa can lead to ischemic injury, which can cause nausea and impaired nutrient absorption.

• Musculoskeletal effects: Fluid and electrolyte imbalances can cause muscle cramps, weakness, and an increased risk of falls, especially in older adults.

History and Physical

A comprehensive history is essential when assessing dehydration, as symptoms and risk factors vary depending on severity and etiology. Early symptoms may include increased thirst, dry mouth, weakness, and decreased urine output. As dehydration worsens, additional symptoms such as dizziness, muscle weakness, palpitations, confusion, and irritability may emerge. In severe cases, lethargy, seizures, and hypovolemic shock can occur. Important historical factors to evaluate include recent fluid intake, excessive fluid losses from vomiting, diarrhea, perspiration, or diuretic use, as well as the presence of underlying conditions such as diabetes, kidney disease, and heart failure.[21]The physical examination may reveal tachycardia, hypotension upon standing, and delayed capillary refill, indicating reduced intravascular volume (see Table 2). In cases of moderate-to-severe dehydration, decreased skin turgor and dry mucous membranes are common. Severe cases may present with confusion, lethargy, or even coma, especially with hypernatremia. Dark-colored urine and oliguria are frequently observed, and in extreme cases, dehydration can lead to shock, characterized by profound hypotension, cool, moist, and clammy skin, and poor circulation to vital organs.[22]

Table

Table 2. Signs and Symptoms of Dehydration.

Evaluation

Laboratory testing is crucial in diagnosing dehydration and assessing electrolyte imbalances. Common findings include an elevated blood urea nitrogen (BUN) to creatinine ratio greater than 20:1, suggesting prerenal azotemia due to reduced renal perfusion.

Specific electrolyte abnormalities vary based on the type of dehydration. Hypernatremia (sodium >145 mEq/L) suggests water-loss dehydration, whereas hyponatremia (sodium <135 mEq/L) indicates sodium-loss dehydration.[17] Hypokalemia is commonly associated with dehydration due to diarrhea or diuretic use, while hyperkalemia in a dehydrated patient may suggest adrenal insufficiency. Elevated hematocrit levels reflect hemoconcentration and reduced plasma volume.

Although no single test is considered the gold standard for diagnosing dehydration, serum osmolality is commonly used, with a value greater than 295 mOsm/kg serving as a reasonable threshold for dehydration due to water loss. However, the accuracy of these tests can be influenced by the rate of fluid loss. When available, a weight loss of 2% or more can indicate dehydration or impending dehydration.[14] A 2015 Cochrane review found that bioelectrical impedance analysis, urine specific gravity, urine osmolality, saliva or tear osmolality, tear volume, urine voiding frequency, and urine volume were unreliable diagnostic tools when used alone in older patients.[21]Urine studies help differentiate the underlying causes of dehydration. A urine specific gravity greater than 1.020 and urine osmolality exceeding 450 mOsm/kg indicate concentrated urine, reflecting renal compensation for fluid loss. Urine sodium levels below 20 mEq/L suggest hypovolemia with an appropriate renal response, while levels greater than 40 mEq/L may indicate renal salt-wasting or adrenal insufficiency. Blood gas analysis can detect acid-base disturbances in severe dehydration, such as metabolic alkalosis in vomiting-induced dehydration or metabolic acidosis, including lactic acidosis.

More severe forms of dehydration may present with shock. Additional tests, such as ultrasound of the inferior vena cava (IVC), can help assess intravascular volume status. An increase in IVC diameter of more than 50% with respiration indicates severe fluid depletion, while IVC collapse with inspiration may correlate with right atrial pressure and intravascular volume.[23] Although IVC ultrasound is useful, its accuracy can be affected by conditions such as cirrhosis, chronic heart disease, and mechanical ventilation.[24] Additionally, IVC sonography has limited value in assessing fluid responsiveness. Noninvasive cardiac output monitoring (NICOM) offers a more comprehensive evaluation of fluid status and can guide individualized fluid management in hypotensive patients.[25]

Treatment / Management

Dehydration treatment focuses on rapid fluid replacement and identifying the underlying cause of fluid loss. The choice of route, type, and volume of fluid therapy depends on the severity of dehydration, electrolyte imbalances, and comorbid conditions. A more cautious approach is necessary for older adults and patients with heart or kidney failure. Please see StatPearls' companion resource, "Fluid Management," for more information.

Mild-to-Moderate Dehydration

Oral rehydration therapy (ORT) is the preferred treatment for mild-to-moderate dehydration. ORT is effective, safe, and less invasive than IV fluid therapy.[26] Recommended oral fluid options include:

• Oral rehydration solutions: The World Health Organization (WHO) recommends solutions containing glucose and electrolytes, including sodium, potassium, chloride, and bicarbonate, to enhance water absorption.

• Homemade oral rehydration solution: 1 teaspoon salt + 6 teaspoons sugar + 1 liter of water.

• Clear liquids: Water, diluted fruit juices, and sports drinks are suitable for mild cases, but excessive sugar intake should be avoided. 

• Beverages to avoid: Certain drinks containing caffeine, alcohol, or carbonation should be avoided, as they can worsen dehydration.

• ORT administration: Adults should consume 1 to 2 liters of oral rehydration solutions over the first 4 hours, continuing as needed to maintain hydration.

Severe Dehydration

When a patient presents with severe dehydration or cannot tolerate ORT, IV fluid therapy is necessary to rapidly restore fluid balance and correct electrolyte disturbances. Common IV fluids used include:

• Isotonic crystalloids (first-line treatment): Normal saline (0.9%) is preferred for treating hypovolemia and most dehydration cases. While effective, administering large volumes may lead to hyperchloremic acidosis.[27] 

  • Lactated ringers contain bicarbonate precursors, which are beneficial in acidotic states, such as in patients with diarrhea or sepsis.

• Hypotonic fluids (for hypernatremic dehydration): Saline (half normal saline, 0.45%) is used to gradually correct hypernatremia while reducing the risk of cerebral edema.

• Dextrose-containing fluids (for hypoglycemia or ongoing fluid loss): 5% Dextrose with 0.9% normal saline (D5-0.9% normal saline) is administered with saline to prevent dilutional hyponatremia, which could occur with 5% dextrose in water (D5W) infusion alone.

In most cases of dehydration, isotonic crystalloid fluids are the preferred choice. However, colloids, such as albumin, may be appropriate in specific circumstances, such as in patients with liver cirrhosis or hypoalbuminemia who do not respond to standard treatments.[28][29]

Electrolyte and Acid-Base Correction

Dehydration often leads to electrolyte imbalances that require prompt correction. Untreated disturbances can lead to severe complications, including cardiac, neurological, and metabolic dysfunction.

• Sodium abnormalities: Sodium abnormalities, including hypernatremia and hyponatremia, are common electrolyte disturbances that require careful management to prevent severe complications.

  • Hypernatremia (>145 mEq/L): This should be corrected slowly with hypotonic fluids, such as 0.45% saline or D5W, at a rate not exceeding 6 to 12 mEq/L per 24 hours to prevent cerebral edema. However, studies suggest that there is no increased risk of mortality, seizures, alteration of consciousness, or cerebral edema, even when the correction rate exceeds 12 mEq/L per 24 hours.[30] 
  • Hyponatremia (<135 mEq/L): If symptomatic (eg, seizures and confusion), hypertonic saline (3% NaCl) should be administered cautiously under close monitoring, with a correction rate not exceeding 4 to 8 mEq/L per 24 hours to avoid osmotic demyelination syndrome.[31]

• Potassium abnormalities: Potassium abnormalities, including hypokalemia and hyperkalemia, require prompt intervention to prevent life-threatening complications.

  • Hypokalemia (<3.5 mEq/L) can be managed based on severity. For mild cases, oral potassium chloride (KCl; 20–40 mEq/d) is recommended. In severe cases, IV potassium (10–20 mEq/h) should be administered, with continuous electrocardiogram (ECG) monitoring to prevent cardiac arrhythmias.
  • Hyperkalemia (>5.5 mEq/L) should be treated with calcium gluconate for cardiac protection. This is followed by an insulin-glucose infusion to shift potassium intracellularly. Loop diuretics may also be used to enhance renal potassium excretion.

• Acid-base balance:

  • Metabolic acidosis (eg, severe diarrhea and diabetic ketoacidosis [DKA]): Bicarbonate therapy should be considered if the blood pH falls below 7.1.
  • Metabolic alkalosis (eg, caused by vomiting or diuretic use): This condition can be corrected by replenishing potassium and chloride deficits with potassium chloride supplementation to restore the acid-base balance.

Treat Underlying Causes

Effective management of dehydration involves replacing fluid and electrolytes and addressing the underlying causes. Treating the root cause helps prevent recurrence and promotes a more complete and lasting recovery.

• Diarrhea or vomiting: Antiemetics, such as ondansetron or metoclopramide, and antidiarrheals, such as loperamide for noninfectious diarrhea, are recommended.
• Diabetes-related dehydration: In DKA, hyperglycemia should be managed with insulin, and fluid replacement should be provided in cases of hyperosmolar hyperglycemic state (HHS).
• Sepsis-induced dehydration: Early IV fluid resuscitation should be initiated, along with prompt antibiotic therapy.
• Diuretic-induced dehydration: Medication should be adjusted, and lost electrolytes should be replenished to restore fluid and electrolyte balance.

Monitoring and Prevention

Regular monitoring and prevention of dehydration are essential to avoid complications and promote optimal health in patients. Consistently assessing fluid status and implementing preventive measures can help reduce the risk of dehydration, particularly in vulnerable populations.

• Monitoring response to treatment: Effective monitoring of clinical signs and laboratory parameters is essential to assess the response to dehydration treatment and ensure optimal hydration status.

  • Clinical signs: Heart rate, blood pressure, urine output, skin turgor, and mental status.
  • Laboratory parameters: Serial measurements of electrolytes, BUN/creatinine, and serum osmolality.
  • Urine output goal: More than or equal to 0.5 mL/kg/h, indicating normal hydration status).

• Prevention strategies: These strategies focus on maintaining proper hydration and minimizing risk factors to reduce the likelihood of dehydration.

  • Adequate fluid intake: At least 2 to 3 L/d of fluid intake is recommended, with adjustments based on activity level, climate, and illness.
  • Hydration in illness: Increased fluid intake is recommended during febrile illness, diarrhea, and vomiting.
  • Diuretics or laxatives: Excessive use of diuretics or laxatives should be avoided, and medications should be adjusted in older patients and those at high risk.

Differential Diagnosis

Dehydration should be differentiated from conditions with similar signs and symptoms, including:

• Gastroenteritis
• Diabetic ketoacidosis
• Hyperosmolar hyperglycemic state
• Sepsis
• Adrenal insufficiency
• Heat stroke or heat exhaustion
• Diuretic overuse
• Gastrointestinal bleeding
• Hypovolemic shock
• Syndrome of inappropriate ADH secretion

Prognosis

The prognosis of dehydration in adults depends on the severity of the condition, underlying causes, comorbidities, and the timeliness of treatment. Mild-to-moderate dehydration typically has an excellent prognosis with prompt oral or IV rehydration. However, severe dehydration carries a higher risk of life-threatening complications if not quickly recognized and appropriately managed.

Prognosis Based on Severity

• Mild-to-moderate dehydration: Most cases resolve quickly with oral or IV fluid replacement, and patients typically recover within 24 to 48 hours if no complications arise.
• Severe dehydration: The prognosis worsens if hypovolemia, electrolyte imbalances, or organ dysfunction develop. If left untreated, severe dehydration can lead to hypovolemic shock, AKI, and multiple organ failure.
• Recurrent or chronic dehydration: Individuals with underlying conditions such as diabetes, kidney disease, heart failure, or neurological disorders are more prone to experience recurrent dehydration, which can lead to long-term complications and worsen underlying health conditions.

Prognostic Factors Affecting Outcome

Various factors affect the clinical outcome of dehydration, as mentioned below.

• Good prognostic factors

  • Early recognition and appropriate oral or IV rehydration.
  • Mild electrolyte disturbances that are quickly corrected.
  • Absence of preexisting renal or cardiovascular disease.

• Poor prognostic factors

  • Severe electrolyte imbalances, such as severe hypernatremia (>160 mEq/L) or hyponatremia (<120 mEq/L), especially when accompanied by neurological symptoms.[32][33] 
  • Complications such as AKI or metabolic acidosis.
  • Older patients with impaired thirst sensation, cognitive impairment, or mobility limitations that hinder access to fluids.[13] 
  • Presence of infections, sepsis, or uncontrolled diabetes (eg, DKA and HHS), which contributes to dehydration.[34][35]

Prognosis in Special Populations

• Older adults: They have a poorer prognosis due to decreased physiological reserve, a blunted thirst response, and the effects of polypharmacy.
• Patients with critical illness: Dehydration increases mortality risk in conditions such as sepsis, AKI, and cardiac dysfunction.
• Diabetic patients: Poor glycemic control increases the risk of dehydration through osmotic diuresis, leading to higher rates of hospitalization and mortality.[34]

Complications

Untreated or severe dehydration can result in serious complications affecting multiple organ systems, including the renal, circulatory, neurological, and metabolic systems. The severity of these complications depends on the degree of dehydration, underlying medical conditions, and the delay in initiating rehydration.

Renal Complications

• Acute kidney injury: Reduced renal perfusion leads to prerenal azotemia, which, if not managed promptly, can progress to acute tubular necrosis.

• Electrolyte imbalances: Dehydration can result in hypernatremia, hyponatremia, hypokalemia, and hyperkalemia, potentially leading to neuromuscular and cardiac dysfunction.

• Kidney stones: Chronic dehydration reduces urine volume and increases solute supersaturation, which promotes the formation of calcium oxalate and uric acid stones.[36]

• Chronic kidney disease: Recurrent episodes of dehydration can contribute to progressive renal damage, particularly in individuals with diabetes or hypertension.[37]

Cardiovascular Complications

• Hypovolemic shock: Severe dehydration can lead to intravascular volume depletion, causing hypotension, tachycardia, and impaired organ perfusion.

• Cardiac arrhythmias: Electrolyte imbalances (such as hypokalemia, hyperkalemia, and hypomagnesemia) may precipitate life-threatening arrhythmias.

• Orthostatic hypotension and falls: Reduced circulating volume can cause dizziness and syncope upon standing, increasing the risk of falls and fractures, particularly in older adults.[38] 

Neurological Complications

• Cognitive impairment and delirium: Dehydration can reduce cerebral perfusion, causing confusion, disorientation, and delirium, particularly in older patients.[39]

• Seizures: Electrolyte imbalances such as hypernatremia or hyponatremia can disrupt neuronal function, leading to seizures and altered mental status.

• Cerebral edema: Rapid correction of hypernatremia can cause osmotic shifts, resulting in brain swelling and increased intracranial pressure.

Gastrointestinal and Hepatic Complications

• Constipation and bowel obstruction: Inadequate fluid intake reduces water content in the stool, potentially leading to severe constipation and fecal impaction.[40]

• Gastrointestinal ischemia (mesenteric ischemia): Decreased blood flow to the intestines may cause ischemic colitis, presenting with abdominal pain, bloody stools, and bowel necrosis.

• Liver dysfunction: Hypovolemia-induced liver hypoperfusion may exacerbate hepatic dysfunction, particularly in patients with cirrhosis.

Musculoskeletal Complications

• Muscle spasms and weakness: Electrolyte imbalances, including sodium, potassium, and magnesium deficiencies, can lead to muscle spasms and weakness.

• Risk of rhabdomyolysis: Severe dehydration, particularly in athletes, military personnel, or patients with critical illness, can trigger muscle breakdown, presenting with myoglobinuria and AKI. Please see StatPearls' companion resource, "Rhabdomyolysis," for more information.

• Falls and fractures: Orthostatic hypotension and muscle weakness increase the risk of injury, especially in older patients.[38]

Metabolic and Endocrine Complications

• Hyperglycemia and diabetic ketoacidosis: In individuals with diabetes, dehydration exacerbates hyperglycemia, increasing the risk of DKA or HHS.[35]

• Metabolic acidosis: Severe dehydration and speis may lead to hypoperfusion and tissue hypoxia, resulting in lactic acidosis.

• Metabolic alkalosis: Dehydration caused by vomiting leads to the loss of hydrochloric acid, resulting in hypochloremic metabolic alkalosis.

Complications in Special Populations

• Older adults: Increased risk of falls, cognitive decline, UTIs, and hospitalizations due to reduced thirst perception and diminished renal function.

• Pregnant women: Dehydration increases the risk of preterm labor, fetal distress, and low amniotic fluid levels (oligohydramnios).[41]

• Critically ill and hospitalized patients: Dehydration can contribute to sepsis, pressure ulcers, impaired wound healing, and multiple organ dysfunction.

Death and Mortality Risk

• Untreated severe dehydration: This carries a high risk of mortality, especially in older adults and critically ill patients.

• Severe hypernatremia: If left untreated, hypernatremia can have a mortality rate as high as 50% when sodium levels exceed 160 mEq/L.[42]

• Hospitalized patients: Severe dehydration requiring hospital admission has a mortality rate of 5% to 15%, especially in older adults, critically ill patients, and individuals with sepsis or multiple organ dysfunction.[33]

Consultations

A nephrologist may be consulted, especially when dehydration is associated with severe hyponatremia or significant electrolyte imbalances that require specialized management. In most cases, however, the primary treating clinician can assess the patient, determine the severity of dehydration, and initiate appropriate fluid replacement therapy. Close monitoring of renal function, serum electrolytes, and the patient’s overall response is essential to ensure safe and effective rehydration.

Deterrence and Patient Education

Although the Centers for Disease Control and Prevention (CDC) does not provide specific water intake recommendations, adults are generally encouraged to consume between 2 and 3 liters of water daily.[43] Patients should adjust fluid intake based on their activity level. For instance, marathon runners require more water compared to individuals with minimal physical activity. Excessive water intake in older adults can lead to hyponatremia; therefore, balanced hydration solutions are recommended to maintain proper electrolyte levels.

Pearls and Other Issues

Key facts to keep in mind about adult dehydration include:

• Dehydration is common in older adults and individuals with certain medical conditions.

• Dehydration is uncommon in adults with no medical problems and unrestricted access to water.

• Adequate fluid volume is essential for optimal bodily function.

• The body uses multiple mechanisms to achieve and maintain euvolemia.

• The diagnosis of volume depletion relies on a comprehensive assessment of the patient’s history, physical examination, and laboratory findings.

• No single definitive test exists for diagnosing dehydration.

• Clinicians should consider a combination of clinical signs and diagnostic markers for diagnosis.

• The primary goal of treatment is to restore the circulating volume.

• The second goal is identifying and addressing the underlying cause to prevent recurrence. 

• In patients with normal cardiac and renal function, liberal fluid administration can rapidly restore volume.

• In patients with heart failure or renal disease, cautious fluid replacement is necessary to avoid fluid overload.

• The optimal strategy involves administering small volumes rapidly, reassessing immediately, and repeating as needed to achieve adequate hydration while minimizing risks.

• The rate of sodium correction for hypernatremia should not exceed 6 to 12 mEq/L per 24 hours to prevent cerebral edema.

• A slower sodium correction is preferred for hyponatremia, with a correction rate not exceeding 4 to 8 mEq/L per 24 hours (ideally 4-6 mEq/L per 24 hours).

• In severe hyponatremia, rapid volume repletion may cause a sharp rise in serum sodium, increasing the risk of central pontine myelinolysis.

• Volume status and sodium levels should be closely monitored throughout treatment.

Enhancing Healthcare Team Outcomes

Effective management of adult dehydration is crucial for improving patient outcomes, ensuring safety, and increasing healthcare efficiency. Healthcare professionals—including physicians, nurses, advanced practitioners, pharmacists, and dietitians—play a key role in the early recognition, timely intervention, and prevention of dehydration-related complications. Critical clinical skills include accurate fluid assessment, electrolyte management, and patient education to ensure proper diagnosis and treatment.

Interprofessional communication through standardized protocols, electronic medical record alerts, and structured multidisciplinary rounds enhances care coordination. Informed consent should be obtained, respecting patient autonomy and ensuring equitable access to hydration therapies for vulnerable populations, including older patients, critically ill individuals, and those with cognitive impairments. Additionally, healthcare teams must carefully balance fluid replacement strategies to prevent overhydration and its associated complications, such as pulmonary edema and electrolyte imbalances.

The management of dehydration through a coordinated, patient-centered approach can significantly reduce hospitalizations, readmissions, and healthcare costs while preventing complications such as AKI, cognitive impairment, and falls.[44] Standardizing hydration protocols in hospitals, nursing homes, and outpatient settings improves patient safety and supports evidence-based practice. Community-based strategies, including public health campaigns and remote hydration monitoring for high-risk groups, provide additional opportunities to reduce dehydration-related morbidity.

Ongoing professional education ensures healthcare teams stay current with best practices, enhancing workflow efficiency, patient safety, and team performance. By incorporating ethical considerations, fostering interprofessional collaboration, and ensuring structured care coordination, healthcare professionals can improve hydration management and optimize overall patient well-being.

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References

1.

Weinberg AD, Minaker KL. Dehydration. Evaluation and management in older adults. Council on Scientific Affairs, American Medical Association. JAMA. 1995 Nov 15;274(19):1552-6. [PubMed: 7474224]

2.

Beck AM, Seemer J, Knudsen AW, Munk T. Narrative Review of Low-Intake Dehydration in Older Adults. Nutrients. 2021 Sep 09;13(9) [PMC free article: PMC8470893] [PubMed: 34579019]

3.

Yun G, Baek SH, Kim S. Evaluation and management of hypernatremia in adults: clinical perspectives. Korean J Intern Med. 2023 May;38(3):290-302. [PMC free article: PMC10175862] [PubMed: 36578134]

4.

Bunn DK, Hooper L. Signs and Symptoms of Low-Intake Dehydration Do Not Work in Older Care Home Residents-DRIE Diagnostic Accuracy Study. J Am Med Dir Assoc. 2019 Aug;20(8):963-970. [PubMed: 30872081]

5.

Molaschi M, Ponzetto M, Massaia M, Villa L, Scarafiotti C, Ferrario E. Hypernatremic dehydration in the elderly on admission to hospital. J Nutr Health Aging. 1997;1(3):156-60. [PubMed: 10995084]

6.

Miller HJ. Dehydration in the Older Adult. J Gerontol Nurs. 2015 Sep 01;41(9):8-13. [PubMed: 26375144]

7.

Kayser-Jones J, Schell ES, Porter C, Barbaccia JC, Shaw H. Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision. J Am Geriatr Soc. 1999 Oct;47(10):1187-94. [PubMed: 10522951]

8.

Paulis SJC, Everink IHJ, Halfens RJG, Lohrmann C, Schols JMGA. Prevalence and Risk Factors of Dehydration Among Nursing Home Residents: A Systematic Review. J Am Med Dir Assoc. 2018 Aug;19(8):646-657. [PubMed: 30056949]

9.

Coppes T, Hazen ACM, Zwart DLM, Koster ES, van Gelder T, Bouvy ML. Characteristics and preventability of medication-related admissions for acute kidney injury and dehydration in elderly patients. Eur J Clin Pharmacol. 2024 Sep;80(9):1355-1362. [PMC free article: PMC11303467] [PubMed: 38831143]

10.

Xiao H, Barber J, Campbell ES. Economic burden of dehydration among hospitalized elderly patients. Am J Health Syst Pharm. 2004 Dec 01;61(23):2534-40. [PubMed: 15595228]

11.

Edmonds CJ, Foglia E, Booth P, Fu CHY, Gardner M. Dehydration in older people: A systematic review of the effects of dehydration on health outcomes, healthcare costs and cognitive performance. Arch Gerontol Geriatr. 2021 Jul-Aug;95:104380. [PubMed: 33636649]

12.

Alsanie S, Lim S, Wootton SA. Detecting low-intake dehydration using bioelectrical impedance analysis in older adults in acute care settings: a systematic review. BMC Geriatr. 2022 Dec 12;22(1):954. [PMC free article: PMC9743772] [PubMed: 36510185]

13.

El-Sharkawy AM, Devonald MAJ, Humes DJ, Sahota O, Lobo DN. Hyperosmolar dehydration: A predictor of kidney injury and outcome in hospitalised older adults. Clin Nutr. 2020 Aug;39(8):2593-2599. [PMC free article: PMC7403861] [PubMed: 31801657]

14.

Li S, Xiao X, Zhang X. Hydration Status in Older Adults: Current Knowledge and Future Challenges. Nutrients. 2023 Jun 02;15(11) [PMC free article: PMC10255140] [PubMed: 37299572]

15.

Schols JM, De Groot CP, van der Cammen TJ, Olde Rikkert MG. Preventing and treating dehydration in the elderly during periods of illness and warm weather. J Nutr Health Aging. 2009 Feb;13(2):150-7. [PubMed: 19214345]

16.

Worfolk JB. Heat waves: their impact on the health of elders. Geriatr Nurs. 2000 Mar-Apr;21(2):70-7. [PubMed: 10769330]

17.

Lacey J, Corbett J, Forni L, Hooper L, Hughes F, Minto G, Moss C, Price S, Whyte G, Woodcock T, Mythen M, Montgomery H. A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications. Ann Med. 2019 May-Jun;51(3-4):232-251. [PMC free article: PMC7877883] [PubMed: 31204514]

18.

Zhang J, Zhang N, Du S, Liu S, Ma G. Acute Water Supplementation Improved the Body Composition of Young Female Adults After Water Restriction of 12 h in Baoding, China: A Randomized Controlled Trial (RCT). Front Nutr. 2022;9:880630. [PMC free article: PMC9251362] [PubMed: 35795583]

19.

Begg DP. Disturbances of thirst and fluid balance associated with aging. Physiol Behav. 2017 Sep 01;178:28-34. [PubMed: 28267585]

20.

Frith J. New horizons in the diagnosis and management of dehydration. Age Ageing. 2023 Oct 02;52(10) [PMC free article: PMC10581537] [PubMed: 37847795]

21.

Hooper L, Abdelhamid A, Attreed NJ, Campbell WW, Channell AM, Chassagne P, Culp KR, Fletcher SJ, Fortes MB, Fuller N, Gaspar PM, Gilbert DJ, Heathcote AC, Kafri MW, Kajii F, Lindner G, Mack GW, Mentes JC, Merlani P, Needham RA, Olde Rikkert MG, Perren A, Powers J, Ranson SC, Ritz P, Rowat AM, Sjöstrand F, Smith AC, Stookey JJ, Stotts NA, Thomas DR, Vivanti A, Wakefield BJ, Waldréus N, Walsh NP, Ward S, Potter JF, Hunter P. Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people. Cochrane Database Syst Rev. 2015 Apr 30;2015(4):CD009647. [PMC free article: PMC7097739] [PubMed: 25924806]

22.

Shimizu M, Kinoshita K, Hattori K, Ota Y, Kanai T, Kobayashi H, Tokuda Y. Physical signs of dehydration in the elderly. Intern Med. 2012;51(10):1207-10. [PubMed: 22687791]

23.

Lamarche J, Rivera AP, Courville C, Taha M, Antar-Shultz M, Reyes A. Role of Point-of-Care Ultrasonography in the Evaluation and Management of Kidney Disease. Fed Pract. 2018 Dec;35(12):27-33. [PMC free article: PMC6366586] [PubMed: 30766335]

24.

Long E, Oakley E, Duke T, Babl FE., Paediatric Research in Emergency Departments International Collaborative (PREDICT). Does Respiratory Variation in Inferior Vena Cava Diameter Predict Fluid Responsiveness: A Systematic Review and Meta-Analysis. Shock. 2017 May;47(5):550-559. [PubMed: 28410544]

25.

Zhu G, Zhang K, Fu Y, Hu Z. Accuracy assessment of noninvasive cardiac output monitoring in the hemodynamic monitoring in critically ill patients. Ann Palliat Med. 2020 Sep;9(5):3506-3512. [PubMed: 33065801]

26.

Ofei SY, Fuchs GJ. Principles and Practice of Oral Rehydration. Curr Gastroenterol Rep. 2019 Dec 07;21(12):67. [PubMed: 31813065]

27.

Monnet X, Lai C, Teboul JL. How I personalize fluid therapy in septic shock? Crit Care. 2023 Mar 24;27(1):123. [PMC free article: PMC10039545] [PubMed: 36964573]

28.

Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R., SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004 May 27;350(22):2247-56. [PubMed: 15163774]

29.

Abedi F, Zarei B, Elyasi S. Albumin: a comprehensive review and practical guideline for clinical use. Eur J Clin Pharmacol. 2024 Aug;80(8):1151-1169. [PubMed: 38607390]

30.

Chauhan K, Pattharanitima P, Patel N, Duffy A, Saha A, Chaudhary K, Debnath N, Van Vleck T, Chan L, Nadkarni GN, Coca SG. Rate of Correction of Hypernatremia and Health Outcomes in Critically Ill Patients. Clin J Am Soc Nephrol. 2019 May 07;14(5):656-663. [PMC free article: PMC6500955] [PubMed: 30948456]

31.

Sterns RH, Hix JK, Silver S. Treatment of hyponatremia. Curr Opin Nephrol Hypertens. 2010 Sep;19(5):493-8. [PubMed: 20539224]

32.

Liamis G, Filippatos TD, Elisaf MS. Evaluation and treatment of hypernatremia: a practical guide for physicians. Postgrad Med. 2016;128(3):299-306. [PubMed: 26813151]

33.

Turkmen E, Karatas A, Altindal M. Factors affecting prognosis of the patients with severe hyponatremia. Nefrologia (Engl Ed). 2022 Mar-Apr;42(2):196-202. [PubMed: 36153916]

34.

Umpierrez G, Korytkowski M. Diabetic emergencies - ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia. Nat Rev Endocrinol. 2016 Apr;12(4):222-32. [PubMed: 26893262]

35.

Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. In: Feingold KR, Ahmed SF, Anawalt B, Blackman MR, Boyce A, Chrousos G, Corpas E, de Herder WW, Dhatariya K, Dungan K, Hofland J, Kalra S, Kaltsas G, Kapoor N, Koch C, Kopp P, Korbonits M, Kovacs CS, Kuohung W, Laferrère B, Levy M, McGee EA, McLachlan R, Muzumdar R, Purnell J, Rey R, Sahay R, Shah AS, Singer F, Sperling MA, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Internet]. MDText.com, Inc.; South Dartmouth (MA): May 9, 2021. [PubMed: 25905280]

36.

Clark WF, Sontrop JM, Huang SH, Moist L, Bouby N, Bankir L. Hydration and Chronic Kidney Disease Progression: A Critical Review of the Evidence. Am J Nephrol. 2016;43(4):281-92. [PubMed: 27161565]

37.

Roncal-Jimenez C, Lanaspa MA, Jensen T, Sanchez-Lozada LG, Johnson RJ. Mechanisms by Which Dehydration May Lead to Chronic Kidney Disease. Ann Nutr Metab. 2015;66 Suppl 3:10-3. [PubMed: 26088040]

38.

Hamrick I, Norton D, Birstler J, Chen G, Cruz L, Hanrahan L. Association Between Dehydration and Falls. Mayo Clin Proc Innov Qual Outcomes. 2020 Jun;4(3):259-265. [PMC free article: PMC7283563] [PubMed: 32542217]

39.

Sfera A, Cummings M, Osorio C. Dehydration and Cognition in Geriatrics: A Hydromolecular Hypothesis. Front Mol Biosci. 2016;3:18. [PMC free article: PMC4860410] [PubMed: 27252943]

40.

De Giorgio R, Ruggeri E, Stanghellini V, Eusebi LH, Bazzoli F, Chiarioni G. Chronic constipation in the elderly: a primer for the gastroenterologist. BMC Gastroenterol. 2015 Oct 14;15:130. [PMC free article: PMC4604730] [PubMed: 26467668]

41.

Zhang N, Zhang F, Chen S, Han F, Lin G, Zhai Y, He H, Zhang J, Ma G. Associations between hydration state and pregnancy complications, maternal-infant outcomes: protocol of a prospective observational cohort study. BMC Pregnancy Childbirth. 2020 Feb 07;20(1):82. [PMC free article: PMC7006388] [PubMed: 32033597]

42.

Jung WJ, Lee HJ, Park S, Lee SN, Kang HR, Jeon JS, Noh H, Han DC, Kwon SH. Severity of community acquired hypernatremia is an independent predictor of mortality. Intern Emerg Med. 2017 Oct;12(7):935-940. [PubMed: 28474207]

43.

Gandy J. Water intake: validity of population assessment and recommendations. Eur J Nutr. 2015 Jun;54 Suppl 2(Suppl 2):11-6. [PMC free article: PMC4473081] [PubMed: 26048039]

44.

Nagae M, Umegaki H, Onishi J, Huang CH, Yamada Y, Watanabe K, Komiya H, Kuzuya M. Chronic Dehydration in Nursing Home Residents. Nutrients. 2020 Nov 20;12(11) [PMC free article: PMC7709028] [PubMed: 33233662]

Disclosure: Kory Taylor declares no relevant financial relationships with ineligible companies.

Disclosure: Alok Tripathi declares no relevant financial relationships with ineligible companies.