What Causes Low Sodium In The Elderly – Hyponatremia is an electrolyte disturbance of low serum sodium that can cause neuropsychiatric symptoms. In psychiatric patients, the most common cause of hyponatremia is syndrome of inappropriate secretion of antidiuretic hormone (SIADH) due to psychotropic drugs, including antidepressants and antipsychotics.

Hyponatremia is defined as a serum sodium ([Na+]) concentration of less than 136 mEq/L (1 mEq/L = 1 mmol/L). This indicates an excess of water relative to sodium in the extracellular fluid (ECF) compartment. The normal range for serum sodium may be 135 to 145 mEq/L.

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Why is hyponatremia important in psychiatry? Hyponatremia is often underdiagnosed and undertreated in both general medicine and psychiatric patients.

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Hyponatremia may cause neuropsychiatric symptoms. Acute hyponatremia can cause delirium and acute behavioral changes that can be mistaken for symptoms of a psychiatric disorder. Other causes of hyponatremia, such as SIADH, may mimic psychiatric disorders or adverse effects of psychotropic medications, and the diagnosis of SIADH may be delayed in psychiatric patients.

Early signs and symptoms of hyponatremia include nausea, vomiting, anorexia, disorientation, headache, fatigue, weakness, irritability, lethargy, confusion, and muscle cramps.

There are many etiologies of hyponatremia. The proper treatment and management of hyponatremia depends on determining the etiology of the hyponatremia. For example, a distinction must be made between iatrogenic hyponatremia (usually due to thiazide diuretics, carbamazepine, antidepressants, or antipsychotics), idiopathic hyponatremia, or other etiologies (such as hypothyroidism or alcoholism). In general, most hyponatremia in the psychiatric population is 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). Hyponatremia associated with selective serotonin reuptake inhibitors in older adults. Annals of Pharmacotherapy, 40 (9), 1618-1622.

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Many psychotropic drugs can cause SIADH either by stimulating the release of vasopressin or by enhancing its action on the renal tubules. It is also believed that psychotropic drugs can also cause stimulation of central serotonin receptors. SIADH is a known side effect of antidepressants, especially in the elderly.

Severe hyponatremia due to SIADH may cause cerebral edema and/or seizures. Treatment of SIAD consists of: (1) fluid restriction (first line), (2) salt tablets, (3) diuretics, (4) ADH antagonists, and/or (5) slow correction of hyponatremia with hypertonic saline to prevent osmotic syndrome demyelination (central pontine myelinolysis).

Psychogenic polydipsia (PPD) (also known as primary polydipsia) is the excessive and voluntary drinking of water commonly used by patients with severe mental illness and/or developmental disability. Psychogenic polydipsia can cause hyponatremia and is associated with minor disturbances in water excretion.

Psychosis, intermittent hyponatremia, and polydipsia syndrome (PIP syndrome) is a triad of symptoms seen in psychiatric patients, particularly those with schizophrenia and/or psychosis.

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The underlying etiology of polydipsia (compulsive drinking of water) remains unclear. Hypotheses include a defect in the central regulation of thirst or treatment with drugs that can cause an altered sensation of thirst.

Usually, the symptoms of this syndrome are subclinical and patients are asymptomatic. However, in more severe cases, death can occur when polydipsia causes severe water intoxication.

Excessive consumption of beer (which has a low solute content) to the exclusion of other fluids can cause severe hyponatremia, known as “beer potomania”.

The incidence of SSRI-induced hyponatremia varies widely, ranging from 0.5% to 32%. In most cases, hyponatremia occurs within the first 2 to 4 weeks after starting treatment. Hyponatremia usually resolves 2 weeks after discontinuation of SSRIs, 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 the syndrome of inappropriate antidiuretic hormone secretion (SIADH) causing hyponatremia.

It is important to distinguish between psychotropic-induced SIADH and psychogenic polydipsia. SIADH should be a diagnosis of exclusion. To differentiate between SIADH and psychogenic polydipsia, it is important to measure serum sodium, osmolality, and urine osmolality.

Siegel, A. J. (2008). Hyponatremia in psychiatric patients: an update on evaluation and management. Harvard Review of Psychiatry, 16(1), 13-24.

Soiza, R.L., & Talbot, H.S. (2011). Management of hyponatremia in the elderly: old threats and new opportunities. Therapeutic Advances in Drug Safety, 2 (1), 9-17.

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Liu, B.A., Mittmann, N., Knowles, S.R. and Shear, N.H. (1996). Hyponatremia and the syndrome of inappropriate antidiuretic hormone secretion associated with the use of selective serotonin reuptake inhibitors: a review of spontaneous reports. CMAJ: Canadian Medical Association Journal, 155(5), 519.

Cheng, J.C., Zikos, D., Skopicki, H.A., Peterson, D.R., and Fisher, K.A. (1990). Long-term neurological outcome in psychogenic water drinkers with severe symptomatic hyponatremia: effect of rapid correction. American journal of medicine, 88(6), 561-566.

Vieweg, W.V.R., David, J.J., Rowe, W.T., Peach, M.J., Veldhuis, J.D., Kaiser, D.L., and Spradlin, W.W. (1985). Psychogenic polydipsia and water intoxication – failed concepts. Biological Psychiatry, 20 (12), 1308-1320.

Goldman, M.B., Luchins, D.J., & Robertson, G.L. (1988). Mechanisms of altered water metabolism in psychotic patients with polydipsia and hyponatremia. New England Journal of Medicine, 318(7), 397-403.

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Lydakis, C., Apostolakis, S., Thalassinos, E., Stamataki, K., Saridaki, K., & Basta, M. (2005). PIP syndrome: a potentially dangerous manifestation of a psychiatric disorder. International Journal of Clinical Practice, 59(5), 612-613.

Kujubu, D. A. and Khosraviani, A. (2015). Beer potomania – an unusual cause of hyponatremia. The Permanente Journal, 19(3), 74.

Leth-Møller, K.B., Hansen, A.H., Torstensson, M., Andersen, S.E., Ødum, L., Gislasson, G., … and Holm, E.A. (2016). Antidepressants and the risk of hyponatremia: a population study based on a Danish registry. BMJ open, 6(5).

Jacob, S. and Spinier, S.A. (2006). Hyponatremia associated with selective serotonin reuptake inhibitors in older adults. Annals of Pharmacotherapy, 40 (9), 1618-1622.

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Kenes, M.T., Hamblin, S.E., Tumuluri, S.S., & Guillamondegui, O.D. (2016). Syndrome of inadequate antidiuretic hormone in a patient treated with high-dose haloperidol and quetiapine. Journal of Neuropsychiatry and Clinical Neurosciences, 28(2), e29-e30. Open Access Policy Institutional Open Access Program Special Issues Guidelines Editorial Process Research and Publishing Ethics Article Processing Fees Awards Disclaimers

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Received: 15 June 2020 / Revised: 15 July 2020 / Accepted: 21 July 2020 / Published: 23 July 2020

Hyponatremia is one of the most common water-electrolyte imbalances in the human body. A serum sodium threshold of less than 135 mmol/L is diagnostic of hyponatremia. The disorder is usually secondary to various diseases, including infections. Our review aims to summarize the diagnostic value and impact of hyponatremia on prognosis, length of hospitalization and mortality in patients with active infection. The scientific literature on hyponatremia was reviewed using the PubMed, ClinicalKey, and Web of Science databases. Studies published between 2011 and 2020 were reviewed and eligible studies were selected according to the PRISMA (Priority Reporting Items for Systematic Reviews and Meta-Analyses) statement and specific inclusion criteria. The most common infections associated with hyponatremia were viral and bacterial infections, including COVID-19 (coronavirus disease 2019). Etiology varied by site of infection, setting, and patient cohort. In several studies, hyponatremia has been associated with prolonged hospitalization, poorer outcomes, and higher mortality rates. Hyponatremia may also have a diagnostic role in differentiating pathogens causing a particular type of infection, as seen in community-acquired pneumonia. Although many mechanisms leading to hyponatremia have been described, it is impossible to attribute the etiology of hyponatremia to any one of them with certainty.

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Hyponatremia is defined as a low concentration of sodium in the blood serum. A sodium concentration below the lower reference limit of 135 mmol/L is diagnostic of this disorder. Hyponatremia is one of the most well-known water-electrolyte imbalances in the human body. Its prevalence among hospitalized patients reaches 15–30%, and is even higher in intensive care units, where it reaches up to 40% [1, 2]. The incidence of hyponatremia in

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