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By CAFMI AI From Nature Reviews Endocrinology
Hyponatremia, defined as a serum sodium concentration below 135 mmol/L, remains the most common electrolyte disorder encountered in clinical settings, especially among elderly patients. This condition is particularly challenging due to the physiological changes associated with aging that disrupt normal sodium and water homeostasis. Aging affects kidney function by reducing glomerular filtration rate, which in turn diminishes the kidney’s ability to clear free water. Alongside this, the elderly experience alterations in hormonal regulation, notably increased sensitivity to antidiuretic hormone (ADH), which promotes water retention. These changes are compounded by decreased thirst perception and reduced fluid intake, often found in older adults, which further complicates fluid balance and predisposes this population to hyponatremia. Additionally, common co-morbidities such as heart failure and liver disease, as well as frequent use of medications that impact fluid and electrolyte status, increase susceptibility. Understanding these physiological changes and recognizing the intricate interplay of risk factors are crucial for clinicians to identify patients at risk and to tailor preventative and diagnostic strategies in their care.
Accurate diagnosis of hyponatremia in elderly patients requires a thorough clinical evaluation combined with laboratory investigations. Hyponatremia is classified based on serum osmolality and volume status into hypotonic, isotonic, and hypertonic types, with hypotonic hyponatremia being the most prevalent. Further classification includes hypovolemic, euvolemic, and hypervolemic hyponatremia, each with different etiologies such as diuretic use, syndrome of inappropriate antidiuretic hormone secretion (SIADH), and heart or liver failure, respectively. Distinguishing these subtypes is essential for appropriate management. Assessment includes measurement of serum and urine electrolytes and osmolality, as well as clinical signs of volume status. In elderly patients, the presence of multiple comorbidities and polypharmacy can complicate the diagnostic process and requires careful interpretation of findings.
Management of hyponatremia in the elderly should be individualized, focusing on the underlying cause and the severity of symptoms. Treatment ranges from fluid restriction to pharmacologic interventions such as vasopressin receptor antagonists. Rapid correction must be avoided to prevent osmotic demyelination syndrome. In mild or chronic cases, slow correction and monitoring are preferred. Prevention involves regular monitoring of sodium levels, especially in patients with risk factors, judicious use of medications, and education on adequate fluid intake. Multidisciplinary approaches involving primary care providers, nephrologists, and pharmacists can improve outcomes. Early recognition and safe correction of hyponatremia help reduce morbidity and mortality in this vulnerable population.
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