Symptoms Of Low Sodium Levels In The Elderly – Hypothermia is a low serum sodium electrolyte imbalance that can cause neuropsychiatric symptoms. The cause of hyponatremia in psychiatric patients is usually secondary to inappropriate antidiuretic hormone secretion (SIADH) from psychotropic drugs.
Hyponatremia is defined as a serum sodium ([Na+]) level of less than 136 meq/L (1 mEq/L = 1 mmol/L). This refers to the amount of water in the extracellular fluid compartment (ECF) relative to sodium. The normal level of serum sodium can range from 135 to 145 mEq/L.
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Symptoms Of Low Sodium Levels In The Elderly
Why is hyponatremia important in psychiatry? Hyponatremia is often underdiagnosed and undertreated in medical and psychiatric patients.
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Hyponatremia can cause neuropsychiatric symptoms. Acute hyponatremia may cause depression and acute behavioral changes that may be mistaken for psychiatric symptoms. Other causes of hyponatremia, such as SIADH, may mimic psychiatric disorders or side effects of psychotropic medications, and the diagnosis of SIADH may be delayed in psychiatric patients.
The first signs and symptoms of hyponatremia are nausea, vomiting, anorexia, confusion, headache, fatigue, weakness, irritability, lethargy, confusion, and muscle cramps.
There are many causes of hyponatremia. Correct treatment and management of hyponatremia depends on identifying the cause of hyponatremia. For example, one must distinguish between iatrogenic hyponatremia (usually caused by thiazide diuretics, carbamazepine, antidepressants, or antipsychotics), idiopathic hyponatremia, or other etiologies (such as hypothyroidism or alcoholism). In general, most hyponatremias in psychiatric patients are associated with physiologically inappropriate (but not necessarily elevated) arginine vasopressin (AVP) levels, leading to water retention and serum hypotonicity.
See also: Jacob, S., & Spinier, S.A. (2006). Hypothermia associated with selective serotonin-reuptake inhibitors in adults. Annals of Pharmacotherapy, 40(9), 1618-1622.
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Many psychotropic drugs can cause SIADH by inducing vasopressin or promoting its action on the renal tubules. In addition, psychotropics are thought to induce stimulation of central serotonin receptors. SIADH is a known side effect of antidepressants, especially in the elderly.
Severe hyponatremia from SIADH can cause cerebral edema and/or seizures. Treatment of SIAD includes (1) fluid restriction (first line), (2) salt tablets, (3) diuretics, (4) ADH antagonists, and/or (5) gradual correction of hyponatremia with hypertonic saline (osmotic demyelination syndrome). Avoid central pontine myelinolysis).
Psychogenic polydipsia (PPD) (also known as primary polydipsia) is an excessive and voluntary intake of water most often in patients with severe mental illness and/or developmental disabilities. Psychogenic polydipsia can cause hyponatremia, and is associated with subtle abnormalities in fluid excretion.
Psychosis, occasional hyponatremia, and polydipsia syndrome (PIP syndrome) are three symptoms seen in psychiatric patients, especially those with schizophrenia and/or psychosis.
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The main cause of polydipsia (compulsive water consumption) is not clear. Hypotheses include impairment of central thirst regulation or drug treatment, which may alter thirst perception.
Usually, the symptoms of this syndrome are subclinical and patients are asymptomatic. However, in severe cases, death can occur when polydipsia causes severe water intoxication.
Drinking too much beer (low solute content) without taking any other liquid can cause severe hyponatremia known as “beer potomania”.
The incidence of hyponatremia caused by SSRIs varies widely, from 0.5% to 32%. In most cases, hyponatremia occurs within 2 to 4 weeks of starting treatment. Hyponatremia typically resolves 2 weeks after SSRI discontinuation, and the incidence returns to population baseline after 3 months.
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Antipsychotics are thought to increase AVP release despite normal plasma osmolality, resulting in hyponatremia leading to the syndrome of inappropriate antidiuretic hormone secretion (SIADH).
It is important to distinguish between psychotropic-induced SIADH and psychological polydipsia. SIADH should be a diagnosis of exclusion. To distinguish between SIADH and psychogenic polydipsia, it is important to measure serum sodium, osmolality and urine osmolality.
Siegel, A.J. (2008). Hypothermia in psychiatric patients: an update on evaluation and management. Harvard Review of Psychiatry, 16(1), 13-24
Soiza, R. L. and Talbot, H.S. (2011) Management of hyponatremia in the elderly: old threats and new opportunities. Medical Advances in Drug Safety, 2(1), 9-17.
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Liu, B.A., Mittmann, N., Knowles, S.R., & Shear, N.H. (1996). Hyponatremia and antidiuretic hormone inappropriate secretion syndrome associated with the use of selective serotonin reuptake inhibitors: a review of case reports. CMAJ: Journal of the Canadian Medical Association, 155(5), 519
Cheng, J.C., Zikos, D., Skopicki, H.A., Peterson, D.R., & Fisher, K.A. (1990) Long-term neurologic outcome in psychogenic water drinkers with severe symptomatic hyponatremia: effect of rapid correction. American Medical Journal, 88(6), 561-566.
Vieweg, W.V.R., David, J.J., Rowe, W.T., Peach, M.J., Veldhuis, J.D., Kaiser, D.L., & Spradlin, W.W. (1985) Psychogenic polydipsia and water intoxication – failed theories. Biological Psychiatry, 20(12), 1308-1320.
Goldman, MB, Luchins, DJ. and Robertson, G.L. (1988) Altered mechanisms of water metabolism in psychotic patients with polydipsia and hyponatremia. New England Journal of Medicine, 318(7), 397-403.
Hyponatremia: Causes, Symptoms, Diagnosis, And Treatment
Lidakis, C., Apostolakis, S., Thalassinos, E., Stamataki, K., Saridaki, K., and Basta, M. (2005) PIP syndrome: a potentially life-threatening psychiatric disorder profile. International Journal of Clinical Practice, 59(5), 612-613.
Kujubu, D. A., and Khosraviani, A. (2015) Brewer’s Potomania – An Uncommon Cause of Hyponatremia. Permanent Journal, 19(3), 74
Leth-Møller, K. B., Hansen, A. H., Torstensson, M., Andersen, S. E., Ødum, L., Gislasson, G., … & Holm, E. A. (2016). Antidepressants and the risk of hyponatremia: a Danish register-based population study. BMJ Open, 6(5).
Jacob, S., & Spinier, S.A. (2006). Hypothermia associated with selective serotonin-reuptake inhibitors in adults. Annals of Pharmacotherapy, 40(9), 1618-1622.
Severe Hyponatremia Correction, Mortality, And Central Pontine Myelinolysis
Kanes, M.T., Hamblin, S.E., Tumuluri, S.S., & Guillamondegui, O.D. (2016). Inappropriate antidiuretic hormone syndrome in a patient receiving high-dose haloperidol and quetiapine therapy. Journal of Neuropsychiatry and Clinical Neuroscience, 28(2), e29-e30. Hypovolemia refers to low extracellular fluid (ECF) levels, often involving decreased water and sodium levels. To maintain body functions and maintain homeostasis (that is, a relatively balanced state), the body needs a certain amount of blood and other body fluids. An imbalance caused by hypovolemia leads to a decrease in ACF, which can affect multiple organs. For example, the heart may start beating faster to compensate for the low ECF.
Hypovolemia is commonly caused by multiple organ failure, such as heart failure or kidney failure. Rarely, neurological diseases, especially those affecting the hormones that control kidney function, can cause hypovolemia.
Another common cause of hypovolemia is dehydration, which can occur due to excessive evaporation from the skin or fever. Without adequate fluid intake, persistent vomiting or diarrhea may occur, which is often associated with infections that cause stomach ulcers.
Hypovolemia can be caused by the accumulation of excess fluid in the interstitial space. For example, if the infection is severe, sepsis can occur, a life-threatening condition in which the individual’s response to the infection causes inflammation of organs and systems. In response, fluids begin to leak into the interstitial space, resulting in hypovolemia. Other conditions that cause fluid to leak out of the veins include pancreatitis, pericarditis, burns, and nutritional hypoalbuminemia.
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Finally, hypovolemia can also occur as a result of sudden blood loss due to a traumatic event, such as a motor vehicle accident or fall from a height. External or internal bleeding can occur and can be life-threatening if not recognized quickly.
Symptoms of general hypovolemia are weakness, fatigue, dizziness and increased thirst. Other more severe symptoms may include low urine output (ie, oliguria), cyanosis due to poor circulation, a bluish discoloration of the skin, abdominal or chest pain, and confusion or decreased level of consciousness.
Many clinical signs can be found during the examination. Some more reliable indicators are an increase in heart rate of 15 to 20 beats per minute while standing (ie, orthostatic tachycardia) or a drop in blood pressure of 10 to 20 mmHg while standing (ie, orthostatic hypotension). Additionally, a decrease in jugular venous pressure (JVP) may indicate hypovolemia.
Severe cases can lead to hypovolemic shock, which occurs when the heart does not have enough fluid to pump effectively. This condition requires urgent medical attention as it can damage the organs if they do not get enough blood. Hypovolemic shock is characterized by tachycardia, hypotension, peripheral hypoperfusion and peripheral vasoconstriction. When hypovolemic shock is caused by bleeding, it is called hemorrhagic shock and when it is caused by sepsis, it is called septic shock.
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Hypovolemia is diagnosed after a medical evaluation that includes signs and symptoms, medical and family history, and physical examination. Next, blood and urine tests, complete blood counts, and chemistry panels (i.e., blood tests that include electrolytes, liver, and kidney function) are often performed. Individuals with renal causes of hypovolemia often show elevated BUN, creatinine, urine sodium concentration, and urine pH. Blood tests can indicate the development of acid-base disorders, such as metabolic acidosis, in individuals with diarrhea. Individuals in hypovolemic shock may experience hepatic or cardiac ischemia, often manifested by chemotherapy.
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