treatment for hyponatremia in elderly

The doctor may even enquire about the patient’s medical history for the purpose of diagnosis. Verbalis and colleagues reported a significant decrease in bone mineralization in rats when their serum sodium concentration was decreased to 110 mEq/L (16). Our articles are resourced from reputable online pages. Do you worry about these elderly patients becoming hypernatremic? Renal ENaC subunit, Na-K-2Cl and Na-Cl cotransporter abundances in aged, water-restricted F344 x Brown Norway rats. Since then she has continued to receive this dose of tolvaptan, and her serum sodium levels over 20 months, without any water restriction, have fluctuated between 135 and 140 mEq/L (Figure 3). The common causes of hyponatremia in elderly range from mild physiological causes to severe illnesses. The SALT trial excluded patients with serum sodium < 120 mEq/L, and the original study with conivaptan enrolled patients with serum sodium as low as 115 mEq/L, but the mean was 124 mEq/L. This antagonist is also metabolized by the CYP3A system, albeit to a lesser degree. Since symptoms of hyponatremia in elderly are non-specific, patients would need to undergo a blood test measuring the sodium level, to confirm the diagnosis of hyponatremia. Why Are Elderly Patients More Prone to Hyponatremia, and What Are the Causes of Hyponatremia in This Population? This dramatic improvement has led me to justify the continued use of the drug in this patient and to recommend a therapeutic trial of tolvaptan in other patients similar to the one presented here—especially elderly patients with hyponatremia in whom water restriction is not tolerated or is ineffective, who have an obvious gait disturbance, or who are otherwise at risk for falls and fractures. However, experience has revealed that adherence with significant water restriction is problematic and that such restriction is poorly tolerated over time. Therefore, at present tolvaptan is the only agent in this class available for long-term oral use. The drug is not Food and Drug Administration (FDA) approved for treatment of hyponatremia. Hyponatremia, a very common problem in older adults, can result in changes in cognition and even seizures if it is not recognized and managed. Mild hyponatremia and risk of fracture in the ambulatory elderly. 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. Hyponatremia in a nursing home population. Thank you for your help in sharing the high-quality science in CJASN. Hyponatremia is especially common in older people. Hyponatremia in elderly age is important to consider as a serious condition because of its potential risk of morbidity and mortality. Published online ahead of print. Symptoms for hyponatremia can range from mild to severe – let’s look at some of them. Age and gender as risk factors for hyponatremia and hypernatremia. 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. Hyponatremia Treatments Since so many different things can cause hyponatremia, your treatment depends on the cause. In contrast, with a serum sodium concentration < 135 mEq/L used as a cutoff, the prevalence of chronic hyponatremia was approximately 20% among residents of a long-term care facility (2). A similar prevalence was noted in a Veterans Affairs nursing home, whereas the prevalence was 8% in ambulatory patients in the same institution (3). Vasopressin receptor antagonists for the treatment of hyponatremia: Systematic review and meta-analysis. They are best described as aquaretic agents, and as such can restore body water content to more normal levels. Thiazide diuretic use was a common contributing factor. 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. Age, race and diet are certain factors which affect one’s chance of getting hyponatremia. Background: The use of antidepressants among elderly is associated with dreaded side effect of hyponatremia. An Elderly Patient with Chronic Hyponatremia, DOI: https://doi.org/10.2215/CJN.03100312. It is critical to establish the underlying cause and type of the hyponatremia in order to address the problem and prevent future occurrences. 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. Hyponatremia as observed in a chronic disease facility. Despite the absence of any scientific support, limitation of water intake is often strongly encouraged. The drug has significant gastrointestinal side effects, is associated with photosensitivity, and can be nephrotoxic, particularly in the presence of liver disease (20). One of the attractive features of the use of vaptans is that water intake need not, and should not, be restricted. During a 24-hour inpatient observation, she was given 15 mg of tolvaptan daily, which resulted in an increase in her serum sodium concentration from 126 to 134 mEq/L. Changing the medicine which affects the sodium level, managing the underlying illness, regulating the intake of water and salt in diet are some simple ways through which hyponatremia can be managed successfully. The severity of the symptoms depends on how low the sodium levels are in the bloodstream and how quickly they fall. Only when the diluting defect is mild and this ratio is <0.5 will a tolerable restriction of approximately 1 L/d be of any therapeutic benefit. The propensity for fractures in elderly hyponatremic patients may not relate solely to gait disturbance but may also be enhanced by a direct effect on bone mineralization. is a 73-year-old woman referred for management of chronic hyponatremia. During this period, her serum sodium concentration ranged between 125 and 132 mEq/L. It is important that the elderly or caregivers do NOT stop medication. Given the absence of liver or heart disease and the patient's apparently normal volume status, she was considered to have euvolemic hyponatremia. Advertisement PDF Version   $34.95      $8.99      Buy Now Kindle Version   $34.95  $8.99      Buy Now Paperback   $74.95         $24.95    Buy Now, Advertisement Kindle Version  $0.99      Buy Now. Serum sodium concentrations before and after initiation of 15 mg of tolvaptan per day. There have been few reports of rechallenge with the same or another SSRI or substitution of another agent from a different therapeutic class. Symptoms of hyponatremia emerged after treatment initiation and resolved with conservative care following discontinuation of duloxetine. 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). The physician may ask to reduce their liquid intake, adjust salt intake and stay under strict monitoring. Therefore, treatment of symptomatic desmopressin-associated hyponatremia with neurologic symptoms can be a clinical challenge. In view of the persistent severe hyponatremia, her inability to maintain a strict water restriction, and her gait instability leading to a fracture, she was considered a good candidate for a vasopressin antagonist. Effect of posture on blood pressure in the elderly. Hyponatremia is a complex condition that demands a systematic approach to diagnosis and management.23 In older adults, hyponatremia is one of the most common electrolyte imbalances and is associated with increased mortality.11 Careful attention to common causes, clinical presentation, laboratory diagnosis, and appropriate treatment will help practitioners safely reverse this potentially life-threatening condition. Hyponatremia associated with large-bone fracture in elderly patients. Magnetic resonance imaging of the brain and pituitary revealed no significant abnormalities. Thus, although urea is inexpensive and potentially effective, its unavailability and patient intolerance regarding its taste make it a limited treatment option. More serious symptoms of hyponatremia in elderly include confusion and disorientation which can further cause gait problems, frequent fall, and fractures. Sodium acts like a vital electrolyte that helps to regulate the water balance in the body. Copyright © 2013 by the American Society of Nephrology. We report the case of an elderly patient who developed hyponatremia most likely related to SIADH induced by duloxetine, an SNRI. 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. This article on Epainassist.com has been reviewed by a medical professional, as well as checked for facts, to assure the readers the best possible accuracy. A 34-year-old member asked: is there a treatment for hyponatremia (low sodium)? Commensurate with the above discussion, our patient had disturbed gait and had sustained a fall and fracture. Also, the presence of some type of illness further increases their risk of developing hyponatremia. Treatment of hyponatremia in elderly depends on its cause. 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. 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. Because it appears to inhibit adenylate cyclase activity after the binding of vasopressin to the V2 receptor (19), this agent also targets the mechanism underlying the pathogenesis of most water-retaining states. Hyponatremia is a medical condition characterized by low concentration of sodium in the blood. 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. Adverse effects were uncommon in most trials and were related mainly to the aquaretic effect of the drugs: polyuria, nocturia, thirst, and dry mouth (27). Also some patients may require … Typical treatment for hypovolemic hyponatremia is administering saline solutions to bring up sodium levels. The syndrome of inappropriate antidiuretic hormone secretion in the elderly. The most recent study designed to determine the prevalence of hyponatremia was limited to patients with severe decrements in serum sodium concentration to <125 mEq/L. 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. For the short-term, we may restrict water intake, adjust or … *Statistical significance. Since then, two competitive V2 receptor antagonists, conivaptan and tolvaptan, have been FDA approved for use in euvolemic and hypervolemic patients with hyponatremia (25). Approximately 10% of the patients given a vaptan report polyuria. 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). Rapid correction of hyponatremia occurs more frequently with vaptans than with placebo (28). 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. The symptoms of hyponatremia in elderly depend on its severity and the underlying cause. Severe hyponatraemia in medical in-patients: Aetiology, assessment and outcome. Although changes in the renal concentrating mechanism brought about by aging have been extensively studied, the effect of aging on the renal diluting process has received much less attention. Treatment of acute and severe form of hyponatremia in elderly may need immediate hospitalization for the administration of intravenous sodium solution in their body to boost their blood sodium level. Traditional treatment for hyponatremia depends on the volume load in the person. In addition, potassium repletion or use of a potassium-sparing diuretic is also often necessary to avoid clinically significant hypokalemia. Does chronic vaptan use alter sensitivity of the collecting duct to endogenous vasopressin once the vaptan is discontinued? 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). Hyponatremia is therefore of special significance in frail older people. Once the patient is discharged, I check the serum sodium concentration 4 days later, then weekly for 2 weeks and then monthly. Advice to remain well hydrated and on use of electrolyte replacement solutions may help prevent hyponatraemia occurring in the setting of acute diarrhoea and/or being sick (vomiting), especially in the elderly and young. A subsequent study also found this association of hyponatremia with large bone fractures in the elderly (14). The placebo-subtracted increase in serum sodium concentration on the first day of drug administration in euvolemic patients was 7.45 mEq/L in a trial with conivaptan (26), 5.60 mEq/L in a large tolvaptan trial (Study of Ascending Levels of Tolvaptan in Hyponatremia [SALT]) (27), and 6.29 mEq/L in a comprehensive meta-analysis (28). The risk of fatality increases for patients with blood sodium level of 110mEq/L, especially if these individuals are also suffering from other underlying related comorbidity. If you have hyponatremia from dehydration, you must have a liquids that have salt (ckn broth or normal saline) in them. 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. 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. With a serum sodium concentration < 136 mEq/L used as a cutoff and a ≤30-year-old cohort as a reference group, patients >60 years had a significantly higher prevalence of hyponatremia both at presentation and as a hospital-acquired disorder (Figure 1). 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. Symptom #1: Muscle Weakness. Treatment of hyponatremia is to find the underlying cause and treat it at the earliest. There is little if any experience with the use of vaptans in patients with serum sodium < 115 mEq/L. 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. She had no history of cardiac or liver disease. 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. 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. 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. BP was 148/78 mmHg, pulse rate was 98 beats/min, and she weighed 65 kg. These agents reliably increase free water excretion and, in contrast to loop diuretics, do not significantly increase urinary sodium or potassium excretion. This article does not have the information I am looking for. Also, use of certain medicines like anti-inflammatory drugs or diuretics, are believed to be some of the common causes of hyponatremia in elderly. 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. 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. In such cases, the symptoms of hyponatremia in elderly usually include nausea, vomiting, headache, muscle cramps, lassitude, irrelevant talking, severe fatigue, seizures and coma. L.G. 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. 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 change in medication has to be done very carefully under the supervision of a medical … Increasing risk for hyponatremia (<136 mmol/L) with age at admission and acquired at hospital. 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. This decision is based on the presence of symptoms, the degree of hyponatremia, whether the condition is acute (arbitrarily defined as a duration of less than 48 hours) or chronic, and the presence of any degree of hypotension. We follow a strict editorial policy and we have a zero-tolerance policy regarding any level of plagiarism. Of 1400 elderly (≥65 years) patients admitted to an Israeli hospital, 6.2% had such a disorder (4). What could be causing this and how should it be treated? A decrease in the expression of the Na-K-2Cl co-transporter in the ascending limb of the loop of Henle and the Na-Cl co-transporter in the distal tubule has been reported in aging rodents (7). Increased susceptibility to thiazide-induced hyponatremia in the elderly. 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. The aim of this review is to practically present the current evidence regarding the thiazide-induced hyponatremia in elderly patients. First, the physician must decide whether immediate treatment is required. Thus, although this approach is potentially effective and inexpensive, more reports of experience with it would be welcome. Rationale: Hyponatremia following duloxetine treatment has been reported in patients with major depressive disorder, fibromyalgia, diabetic neuropathy, or sciatic pain. Enter multiple addresses on separate lines or separate them with commas. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. The numbers in the parentheses (1, 2, 3) are clickable links to peer-reviewed scientific papers. 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. This decrement is further enhanced if they are receiving thiazide diuretics or nonsteroidal anti-inflammatory drugs, both of which are commonly used in this population. Treatment of Low Sodium in the Elderly. 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