Hyponatremia is the most common electrolyte disorder. Do you worry about these elderly patients becoming hypernatremic? In conclusion, both the evaluation and the treatment of hyponatremia constitute many challenges in the elderly population. Question 1. Such a trial has not yet been undertaken in the patient under discussion. However, the loss of these solutes, although critical to the cell volume adaptive process, leaves the brain with a decreased amount of various substances, such as glutamine, a major neurotransmitter, that are important for normal neuronal function (10). Optimal treatment of hyponatremia in clinical practice Volker Burst*1, Marco Witthus1, Franziska Grundmann1, Roman-Ulrich Müller1 & Torsten Kubacki1 1Department II of Internal Medicine & Center for Molecular Medicine Cologne, University of Cologne, Kerpener Straße 62, 50937 Köln, Germany *Author for correspondence: Tel. With the aging of the population and the greater propensity of the elderly to develop hyponatremia, this electrolyte disorder is of increasing importance to the practicing nephrologist. Thus, the rationale for initiating a therapeutic intervention to increase her serum sodium concentration appeared compelling. The treatment of hyponatremia depends on the type of hyponatremia and special attention is also needed to correct serum sodium levels at the appropriate rate, especially in chronic hyponatremia, in order to avoid the osmotic demyelination syndrome. Furthermore, these investigators reported significant disturbances in gait in 12 “asymptomatic” hyponatremic patients with a mean serum sodium of 128 mEq/L that were worse than those observed in patients with blood alcohol levels of 0.05%; these gait abnormalities corrected when the serum sodium levels returned to normal. In this Attending Rounds, an illustrative patient with hyponatremia is presented. Also characteristic of this syndrome in the elderly is the lack of a clear underlying cause in >50% of cases (4,9). Shock resulting from volume depletion should be tr… Treatment of hyponatremia is to find the underlying cause and treat it at the earliest. Hyponatremia widely affects the geriatric age group, especially hospitalized elderly patients. Whether such downregulation occurs in humans is not known, but if present it could impair both maximal concentrating and diluting abilities. Commensurate with the above discussion, our patient had disturbed gait and had sustained a fall and fracture. In case of patients suffering from congestive heart failure, chronic renal failure and chronic liver disease, … The presence of these conditions usually increases the risk of hyponatremia in elderly. Reprinted from reference 5, with permission. Figure 1 shows the course of treatment and the changes in the serum sodium concentration of the case subject. Find a Physician                            Privacy Policy, Images and Text Policy                Editorial Policy, Information Policy                        Advertising Policy, Financial Disclosure Policy          Cookie Policy, About Us                                        Contact Us. Diuretics can lead to varying degrees of hyponatraemia. The SALT trial with tolvaptan did demonstrate a significant (P=0.015) improvement in the score on the mental, but not the physical, component of the Short-Form 12 general health survey at 30 days (27). Because a broad range of pulmonary disorders are associated with SIADH, bronchiectasis was considered to be the cause of the syndrome, particularly in view of the normal findings on magnetic resonance imaging of the brain. A subsequent case-control study of >530 patients with a mean age of 81 years also found that the presence of hyponatremia (mean serum sodium concentration, 131 mEq/L) was associated with a four-fold greater risk of presenting with a fracture compared with age-matched normonatremic controls (13). In many cases, blood sodium levels fall gradually, producing only mild symptoms as the body has time to make adjustments. The second step is to determine the most appropriate method of correcting the hyponatremia. More serious symptoms of hyponatremia in elderly include confusion and disorientation which can further cause gait problems, frequent fall, and fractures. Why Should Increasing the Serum Sodium in the Patient under Discussion Be Considered? Assessment of the efficacy and safety of intravenous conivaptan in euvolemic and hypervolemic hyponatremia. Thus, although these patients may appear to be asymptomatic, more careful studies have led to the question “Does asymptomatic hyponatremia exist?” (11). Her neurologic examination revealed that she was fully oriented, with no focal findings, but she had an obvious gait disturbance that necessitated a walker for ambulation. Treatment Guidelines For Hyponatremia. In this trial the serum sodium exceeded 146 mEq/L in fewer than 2% of the patients who received this vaptan. Rationale: Hyponatremia following duloxetine treatment has been reported in patients with major depressive disorder, fibromyalgia, diabetic neuropathy, or sciatic pain.
Hyponatremia is the most common electrolyte disorder. The risk for osmotic demyelination is higher with lower initial serum sodium concentration. Publication date available at www.cjasn.org. In addition, potassium repletion or use of a potassium-sparing diuretic is also often necessary to avoid clinically significant hypokalemia. The increasing prevalence of hyponatremia with age is best illustrated in an analysis of >300,000 samples obtained from >120,000 patients of various ages (5). Therefore, treatment of symptomatic desmopressin-associated hyponatremia with neurologic symptoms can be a clinical challenge. Since then, two competitive V2 receptor antagonists, conivaptan and tolvaptan, have been FDA approved for use in euvolemic and hypervolemic patients with hyponatremia (25). Therefore, interactions with drugs that are also metabolized by this pathway result in increased concentration of both drugs and require dose adjustment. is a 73-year-old woman referred for management of chronic hyponatremia. The administration of urea in doses ranging from 30 to 90 g/d can successfully increase the serum sodium concentration in patients with chronic hyponatremia. Increasing risk for hyponatremia (<136 mmol/L) with age at admission and acquired at hospital. The response rate is extremely variable. Hyponatremia is also associated with a higher risk of death. There is no US Pharmacopeia–approved formulation, and it is not available at most pharmacies. Mild hyponatremia as a risk factor for fractures: The Rotterdam Study. The author thanks Dr. Geraldine Currigan for referring the patient, and L.G. As long as the thirst response is intact, significant hypernatremia should not develop. It is used in doses ranging from 600 to 1200 mg per day if water restriction becomes ineffective and the underlying cause of the hyponatremia is not readily reversible or treatable. Depending on the common causes of hyponatremia in elderly and the existing symptoms, additional blood tests, imaging tests and urine tests be ordered.eval(ez_write_tag([[468,60],'epainassist_com-banner-1','ezslot_9',149,'0','0'])); Hyponatremia in elderly is considered to be a serious condition because of the associated risk of morbidity and mortality. There were deformities of the proximal interphalangeal joints. The feedback link “Was this Article Helpful” on this page can be used to report content that is not accurate, up-to-date or questionable in any manner. For the short-term, we may restrict water intake, adjust or … Serum sodium concentrations before and after initiation of 15 mg of tolvaptan per day. Treatment of Low Sodium in the Elderly. These agents reliably increase free water excretion and, in contrast to loop diuretics, do not significantly increase urinary sodium or potassium excretion. We follow a strict editorial policy and we have a zero-tolerance policy regarding any level of plagiarism. Although a recent study by Soupart and colleagues in 13 patients with SIADH found that urea was as effective in raising serum sodium levels and was as well tolerated as the vasopressin antagonist tolvaptan (23), in my experience and in informal surveys of practicing nephrologists in North America, urea is not widely used in North America, primarily because of limited availability. However, experience has revealed that adherence with significant water restriction is problematic and that such restriction is poorly tolerated over time. Renal ENaC subunit, Na-K-2Cl and Na-Cl cotransporter abundances in aged, water-restricted F344 x Brown Norway rats. The doctor may even enquire about the patient’s medical history for the purpose of diagnosis. *Statistical significance. These changes would result in increased delivery of solute to more distal sites of the nephron, limiting free water clearance. Of 1400 elderly (≥65 years) patients admitted to an Israeli hospital, 6.2% had such a disorder (4). noted that approximately 7% of patients >65 years of age had serum sodium concentrations ≤ 137 mEq/L (1). Symptoms of hyponatremia emerged after treatment initiation and resolved with conservative care following discontinuation of duloxetine. Its poor palatability also leads to poor adherence. An open-label trial demonstrated continued efficacy of tolvaptan to maintain serum sodium level >135 mEq/L in most treated patients for up to 4 years (Figure 2) (29). Once the patient is discharged, I check the serum sodium concentration 4 days later, then weekly for 2 weeks and then monthly. Hyponatremia as observed in a chronic disease facility. Hyponatremia associated with large-bone fracture in elderly patients. A 34-year-old member asked: is there a treatment for hyponatremia (low sodium)? BP was 148/78 mmHg, pulse rate was 98 beats/min, and she weighed 65 kg. Contact

Do you worry about these elderly patients becoming hypernatremic? This article does not provide medical advice. Long-term effect of tolvaptan on serum sodium in the SALTWATER trial. Age, race and diet are certain factors which affect one’s chance of getting hyponatremia. Clearly patients with more severe hyponatremia need to be monitored very closely. For treatment of moderate and chronic hyponatremia in elderly, caused by excessive intake water and fluids, improper diet or consumption of diuretics, appropriate changes are advised. If you have mild symptoms, your doctor makes small adjustments to your therapy to correct the problem. Sodium acts like a vital electrolyte that helps to regulate the water balance in the body. This occurs because of confusion and disorientation that commonly is a symptom in hyponatremia. This article may contains scientific references. Hyponatremia causes neurologic symptoms ranging from confusion to seizures to coma. The treatment for hyponatremia depends on the underlying cause of the condition. The symptoms of hyponatremia in elderly too vary depending on the severity of the illness. In view of the limitations of other available therapies described above, the development of antagonists to the hydro-osmotic effect of vasopressin via its V2 receptor has received significant attention. These observations may be related to stimulation of osteoclastic activity and enhanced bone resorption in the setting of a low serum sodium concentration (17). Finally, in a case-control study of 122 hyponatremic patients (mean serum sodium, 126 mEq/L; mean age, 72 years), these investigators found that the gait disturbance associated with hyponatremia culminated in an increase in risk for falls by an odds ratio of 67.4 (95% confidence interval [CI], 7.48–607.4; P<0.001). The symptoms of hyponatremia in elderly depend on its severity and the underlying cause. In this regard, Renneboog and colleagues administered a battery of visual and auditory tests to 16 patients with chronic hyponatremia (mean age, 63 years; mean serum sodium concentration, 128 mEq/L) (12). Clinical Journal of the American Society of Nephrology, A Patient with a Novel Gene Mutation Leading to Autosomal Dominant Polycystic Kidney Disease, A Woman with ESRD with Increasing Need for Erythropoietin to Maintain Hemoglobin. Hyponatremia, a very common problem in older adults, can result in changes in cognition and even seizures if it is not recognized and managed. No studies have compared this therapeutic approach with other therapies for chronic hyponatremia in the elderly. The single most common cause of hyponatremia was SIADH. Hyponatremia treatment is aimed at addressing the underlying cause, if possible.If you have moderate, chronic hyponatremia due to your diet, diuretics or drinking too much water, your doctor may recommend temporarily cutting back on fluids. How significant is the burden of polyuria on patients who are receiving long-term vaptan therapy? Question 4. Hyponatremia is a medical condition characterized by low concentration of sodium in the blood. The drug has significant gastrointestinal side effects, is associated with photosensitivity, and can be nephrotoxic, particularly in the presence of liver disease (20). Symptoms are more serious when blood sodium levels fall quickly. The various available treatment approaches, including water restriction, demeclocycline, loop diuretics with NaCl supplementation, urea, and vasopressin antagonists are summarized, with emphasis on the efficacy and limitations of each of these therapies. The reasons for the increased incidence and prevalence of hyponatremia in the elderly are discussed, with emphasis on the effects of aging on urinary dilution, the frequently multifactorial nature of hyponatremia in this population, and the absence of a definite cause for inappropriate and persistent vasopressin release in many such patients. Question 2. These physiological changes in the water regulatory system of the body, makes hyponatremia more common in the elderly. This article contains incorrect information. Special attention is also needed to correct serum sodium levels at the appropriate rate, especially in chronic hyponatremia, in order to avoid the osmotic demyelination syndrome. Nonetheless, studies primarily designed to assess whether morbidity, length of hospitalization, overall well-being (preferably with a disease-specific instrument), and even mortality are urgently needed to determine whether the long-term use of these costly agents is justified. It does so by inducing a solute (urea) diuresis that, by increasing urine flow rate, decreases the concentration of sodium and potassium in the urine and hence increases excretion of electrolyte-free water (22). In fact, thirst was one of the more frequent complaints in the SALT trials, even when serum sodium was nowhere near the normal range. The change in medication has to be done very carefully under the supervision of a medical … In the elderly hypertensive patient (assuming body weight of 70 kg) with mild to moderate hyponatremia free water excess is around 2.5 L. One bottle of Nepro/day will generate about 120 mosm to be excreted via urine. What could be causing this and how should it be treated? In the last year she has had increased gait instability and sustained a fall that resulted in a pelvic fracture. Dr. Ramin Rafie answered. 29, with permission. Nonetheless, because the elderly are more prone to hypodypsia they may be at greater risk to develop this problem. In this study as well, patients with SIADH and heart failure had a more robust response than those with cirrhosis. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. However, to prevent undesirable concomitant sodium depletion, this treatment also requires the administration of NaCl, typically 2–3 g daily, to supplement dietary intake. Findings from another study suggest that correction of sodium and calcium concentration levels in GC patients with severe hyponatremia or hypocalcemia allows for additional treatments and result in significantly better OS.32 Thus, we propose that more attention should be paid to improve the hyponatremic or hypocalcemia status in elderly patients. She has had four pulmonary bacterial infections during the last 7 years and was found to have radiologic evidence of bronchiectasis. Nonetheless, most elderly persons have well preserved urinary diluting ability, and the development of hyponatremia is likely to supervene only when additional pharmacologic or pathologic processes are operant, as they frequently are with advancing age. Treatment of the syndrome of inappropriate secretion of antidiuretic hormone with furosemide. For those who are euvolemic (normal body volume load), fluid intake should be restricted. This is particularly important in view of the high cost of this treatment. Heart failure is also a common comorbid condition in this age group. Intravenous fluids. As noted above, in some patients treated with vaptans, increments in the serum sodium concentration that exceed desired limits were exceeded. Laboratory results were as follows: serum sodium, 124 mEq/L; chloride, 95 mEq/L; potassium, 4.1 mEq/L; bicarbonate, 22 mEq/L; creatinine, 0.7 mg/dl; glucose, 66 mg/dl; and uric acid, 3.8 mg/dl. In this meta-analysis, the response was more modest in hypervolemic patients, at 4.09 mEq/L (28). During this period, her serum sodium concentration ranged between 125 and 132 mEq/L. Most cases of prolonged hyponatremia in the elderly are related to medication. In case of patients suffering from congestive heart failure, chronic renal failure and chronic liver disease, the doctor may restrict their fluid intake and even adjust the dose of diuretics. Although a decrement in tonicity should in itself suppress thirst, a large portion of fluid intake is not driven by thirst but rather is determined by habit and other factors. As a disorder whose pathogenesis revolves around the retention of water and the kidney's reduced ability to excrete it, the cornerstone of treatment of chronic hyponatremia has been restriction of water intake. Nonetheless, the goal of increasing the serum sodium concentration by 6–8 mEq/L in the first 24 hours should be attended to, and patients should be allowed free access to water in order to mitigate excessive correction rates. The physician may ask to reduce their liquid intake, adjust salt intake and stay under strict monitoring. Some of the common causes of hyponatremia in elderly include co-existing diseases like dehydration, chronic kidney failure, congestive cardiac failure, lung disease, chronic liver disease and urinary tract infection. A third agent, lixivaptan, is under review by the FDA. Furthermore, water restriction is not always effective, particularly when the diluting defect is severe. Approximately 10% of the patients given a vaptan report polyuria. The drug is not Food and Drug Administration (FDA) approved for treatment of hyponatremia. These are intriguing questions that to my knowledge have not been studied, but certainly should be because the answers have important clinical implications. Hyponatremia in a euvolemic patient can be managed with fluid restriction and discontinuation of any medications that affect free-water excretion, along with initiation of treatment of the underlying cause. Dr. Berl was formerly on Otsuka's speaker's bureau. The aim of this review is to practically present the current evidence regarding the thiazide-induced hyponatremia in elderly patients. For treatment of moderate and chronic hyponatremia in elderly, caused by excessive intake water and fluids, improper diet or consumption of diuretics, appropriate changes are advised. Thiazide diuretic use was a common contributing factor. Her husband reports that her gait has significantly improved, and she has had no further falls. This Attending Rounds will pose a series of questions to address the incidence and prevalence of hyponatremia in the elderly, its causes and pathogenesis, whether it should be treated, and the therapeutic options available for treatment of chronic hyponatremia. More important, adults with mild hyponatremia (mean serum sodium concentration, 133 mEq/L) displayed a significantly increased risk for osteoporosis at the hip (odds ratio, 2.85; 95% CI, 1.03–7.86) and femoral neck (odds ratio, 2.87; 95% CI, 1.41–5.81). It must be recognized that there is a serious paucity of data demonstrating that vaptans clearly improve patient outcomes. The various available treatment approaches, including water restriction, demeclocycline, loop diuretics with NaCl supplementation, urea, and vasopressin antagonists are summarized, with emphasis on the efficacy and limitations of each of these therapies. 2. Special attention is also needed to correct serum sodium levels at the appropriate rate, especially in chronic hyponatremia, in order to avoid the osmotic demyelination syndrome. Thus, the response to this therapeutic intervention is variably effective and is often insufficient to adequately correct significant hyponatremia. Characterization of a novel aquaretic agent, OPC-31260, as an orally effective, nonpeptide vasopressin V2 receptor antagonist. Background: The use of antidepressants among elderly is associated with dreaded side effect of hyponatremia. At the same time it also depends on the severity of … This article does not have the information I am looking for. Intervention/treatment ; Hyponatremia in Elderly: Diagnostic Test: serum sodium: Detailed Description: These patients are also at a higher risk of the complications of hyponatremia such as brain injury, the main result of acute symptomatic hyponatremia and associated with significant morbidity and mortality. She was known to have had hyponatremia for several years, with serum sodium levels in the range of 121–127 mEq/L. Ask doctors free . Although the high cost of the drug is a frequent impediment to its long-time use, her insurance company was willing to cover the cost. The patient had difficulty adhering to this because of mouth dryness. Increased susceptibility to thiazide-induced hyponatremia in the elderly. Doctors give trusted, helpful answers on causes, diagnosis, symptoms, treatment, and more: Dr. Front on treatment for hyponatremia in elderly: There are many different types of treatment. The treatment of hyponatremia depends on the type of hyponatremia. Of note is that when multiple serum sodium measurements were made during a 12-month period, approximately half of the nursing home population had at least one serum sodium measurement < 135 mEq/L. Correlation in hyponatremic cirrhotic patients. Recent evidence highlights that even mild, chronic hyponatremia can lead to cognitive impairment, falls and fractures, the latter being in part due to bone demineralization and reduced bone quality. Severe hyponatraemia in medical in-patients: Aetiology, assessment and outcome. On physical examination she appeared to be a fragile elderly woman in no acute distress. The common causes of hyponatremia in elderly range from mild physiological causes to severe illnesses. Presence of neurological symptoms and the severity of hyponatremia also play an important role in determining the right course of treatment of hyponatremia in elderly. Let us look at the common causes of hyponatremia in elderly, it symptoms and treatment. Other drugs associated with development of hyponatremia in the elderly population include the sulfonylurea chlorpropamide, the anticonvulsant carbamazepine, and the antineoplastic agents vincristine, vinblastine, and cyclophosphamide. Hyponatremia was associated with an increase in error rate and latency time that was highly significant compared with patients who had a normal serum sodium concentration. The rationale for treating the hyponatremia, even when apparently asymptomatic, is discussed, with attention to cognitive function, gait, and bone structure disturbances that increase the risk for fractures. Milder type of hyponatremia can cause extreme malaise and lethargy while in its severe form, hyponatremia can trigger confusion, altered sensorium and even death. One of the attractive features of the use of vaptans is that water intake need not, and should not, be restricted. Treatment of isovolemia hypotonic hyponatremia associated with SSRI use includes water restriction and mild diuresis with a loop diuretic. I have a 95 year old nursing home patient (Jessie) with a serum sodium level of 128. In those that are hypovolemic (low body volume load), give isotonic saline. Get To Know What Possibly Could Be Causing Your Symptoms! This approach has the virtue of addressing the underlying responsible mechanism and is very attractive for its lack of any associated cost. There is little if any experience with the use of vaptans in patients with serum sodium < 115 mEq/L. Published online ahead of print. Hyponatremia in a nursing home population. Therefore, at present tolvaptan is the only agent in this class available for long-term oral use. Result of a cosyntropin stimulation test was normal, with a baseline cortisol level of 9.2 μg/dl and a stimulated level of 18.7 μg/dl. Our articles are resourced from reputable online pages. Vasopressin receptor antagonists for the treatment of hyponatremia: Systematic review and meta-analysis. It is critical to establish the underlying cause and type of the hyponatremia in order to address the problem and prevent future occurrences. 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