Hypernatremia in the geriatric population

Extreme Hypernatremia due to Dehydration

Hypernatremia is defined as having a serum sodium concentration exceeding 145 mmol/L (normal range is 136 - 145 mmol/L). When the serum sodium level surpasses 160 mmol/L and 190 mmol/L, it is classified as severe and extreme hypernatremia, respectively. Extreme hypernatremia is an uncommon occurrence and is associated with significant risks of mortality and morbidity. The most frequently reported causes of extreme hypernatremia are accidental or intentional salt ingestion and diabetes insipidus, while dehydration due to poor water intake as a trigger for extreme hypernatremia is rarely documented. Here, we present a case study of an elderly patient who experienced extreme hypernatremia with a serum sodium level of 191 mmol/L due to dehydration and had altered mental status and ventriculomegaly as a complication.

Outcome of Hospitalized Cancer Patients with Hypernatremia: A Retrospective Case-Control Study

Hypernatremia (>145 mmol/L) is a relatively rare event, and the data regarding its role in the outcome of inpatients on an oncology ward are weak. The aim of this study was to describe the prevalence, prognosis, and outcome of hospitalized cancer patients with hypernatremia. We performed a retrospective case-control study of data obtained from inpatients with a solid tumor at the St. Claraspital, Basel, Switzerland, who were admitted between 2017 and 2020. The primary endpoint was overall survival. Hypernatremia was found in 93 (3.16%) of 2945 inpatients bearing cancer or lymphoma. From 991 eligible normonatremic control patients, 93 were matched according to diagnosis, age, and sex. The median overall survival time (OS) of patients with hypernatremia was 1.5 months compared to 11.7 months of the normonatremic controls (HR 2.69, 95% CI 1.85-3.90, p < 0.0001). OS of patients with irreversible compared to reversible hypernatremia was significantly shorter (23 versus 88 days, HR 4.0, 95% CI 2.04-7.70, p < 0.0001). The length of hospital stay was significantly longer for the hypernatremic than for the normonatremic group (p < 0.0001). Significantly more patients with hypernatremia died in the hospital (30.1% versus 8.6%, p < 0.001). These results suggest hypernatremia to be associated with an unfavorable outcome and a very short OS.

Diagnostic and therapeutic approach to hypernatremia

Hypernatremia occurs when the plasma sodium concentration is greater than 145 mmol/L. Depending on the duration, hypernatremia can be differentiated into acute and chronic. According to severity: mild, moderate and threatening hypernatremia. Finally, depending on pathogenesis, hypernatremia can be defined as hypervolemic, hypovolemic, and euvolemic. Acute hypervolemic hypernatremia is often secondary to increased sodium intake (hypertonic NaCl and NaHCO₃ solutions). Instead, chronic hypervolemic hypernatremia may be an expression of primary hyperaldosteronism. Euvolemic hypernatremia occurs in diabetes insipidus: depending on the underlying pathogenesis, it can be classified into two basic types: neurogenic (or central) and nephrogenic. The neurogenic form may be triggered by traumatic, vascular or infectious events; the nephrogenic form may be due to pharmacological causes, such as lithium, or non-pharmacological ones, such as hypokalemia. For hypovolemic hypernatremia, possible explanations are renal or extrarenal losses. The main goal of treatment of hypernatremia is the restoration of plasma tonicity. In particular, if the imbalance has occurred acutely, rapid correction improves the prognosis by preventing the effects of cellular dehydration; if hypernatremia has developed slowly, over a period of days, a slow correction rate (no more than 0.4 mmol/L/h) is recommended.

Serum Sodium Levels Predict Mortality in Elderly Acute Kidney Injury Patients: A Retrospective Observational Study

Purpose

We examined the relationship between different levels of serum sodium and mortality among elderly patients with acute kidney injury (AKI).

Methods

We retrospectively enrolled elderly patients from Chinese PLA General Hospital from 2007, to 2018. All-cause mortality was examined according to eight predefined sodium levels: <130.0 mmol/L, 130.0–134.9 mmol/L, 135.0–137.9 mmol/L, 138.0–141.9 mmol/L, 142.0–144.9 mmol/L, 145.0–147.9 mmol/L, 148.0–151.9 mmol/L, and ≥152.0 mmol/L. We estimated the risk of all-cause mortality using a multivariable adjusted Cox analysis, with a normal sodium level of 135.0–137.9 mmol/L as a reference.

Results

In total, 744 patients were suitable for the final evaluation. After 90 days, the mortality rates in the eight strata were 36.1, 27.8, 19.6, 24.4, 30.7, 48.6, 52.8, and 57.7%, respectively. In the multivariable adjusted analysis, patients with sodium levels <130.0 mmol/L (HR: 2.247; 95% CI: 1.117–4.521), from 142.0 to 144.9 mmol/L (HR: 1.964; 95% CI: 1.100–3.508), from 145.0 to 147.9 mmol/L (HR: 2.942; 95% CI: 1.693–5.114), from 148.0 to 151.9 mmol/L (HR: 3.455; 95% CI: 2.009–5.944), and ≥152.0 mmol/L (HR: 3.587; 95% CI: 2.151–5.983) had an increased risk of all-cause mortality. After 1 year, the mortality rates in the eight strata were 58.3, 47.8, 33.7, 38.9, 45.5, 64.3, 69.4, and 78.4%, respectively. Patients with sodium levels <130.0 mmol/L (HR: 1.944; 95% CI: 1.125–3.360), from 142.0 to 144.9 mmol/L (HR: 1.681; 95% CI: 1.062–2.660), from 145.0 to 147.9 mmol/L (HR: 2.631; 95% CI: 1.683–4.112), from 148.0 to 151.9 mmol/L (HR: 2.411; 95% CI: 1.552–3.744), and ≥152.0 mmol/L (HR: 3.037; 95% CI: 2.021–4.563) had an increased risk of all-cause mortality.

Conclusion

Sodium levels outside the interval of 130.0–141.9 mmol/L were associated with increased risks of 90-day mortality and 1-year mortality in elderly AKI patients.

Fluid Intake Recommendation Considering the Physiological Adaptations of Adults Over 65 Years: A Critical Review

The aim of this critical review was to clarify recommended fluid intake for older people. A literature search of published articles and guidelines on fluid intake recommendations until April 2020 was carried out using PUBMED, Scopus, Cochrane, and Google Scholar. In this review, we focused on people over 65 years old at different care levels. The results show that the mean fluid intake ranges between 311 and 2390 mL/day. However, it is difficult to know whether this corresponds to the real pattern of fluid intake, due to the variability of data collection methods. With respect to the recommendations, most international organizations do not take into consideration the physiology of ageing or the health problems associated with an older population. In conclusions, we recommend to follow the guideline of the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Food Safety Authority (EFSA). ESPEN is the only guideline which takes into account age. It is also based on EFSA recommendations. This authority takes into consideration all fluids consumed (ranging from food to fluids). If it is known that around 20% of all fluids consumed come from food, the result would effectively be that the EFSA recommends the same as the ESPEN guidelines: 1.6 L/day for females and 2.0 L/day for males. The findings could help raise the awareness of professionals in the sector with respect to the required fluid intake of the elderly and, in this way, contribute to avoiding the consequences of dehydration.

Where there is sodium there may be sepsis

Hypernatremia affects up to 9% of critically ill patients upon hospital admission, especially in elderly patients with thirst impairment. However, hypernatremia is not entirely explained by fluid imbalance. Recent studies suggest that sodium is an important enhancer of the immune system, raising the question of whether inflammatory states such as sepsis may contribute to hypernatremia. Although sepsis patients with hypernatremia face a greater mortality rate, there is a lack of studies examining a potential association between hypernatremia and sepsis. Motivated by the frequent concurrence of hypernatremia and sepsis observed at an eastern Pennsylvanian community hospital, the current study was conducted to evaluate whether hypernatremia on admission may serve as a potential surrogate marker for sepsis. The medical records of 153 patients with hypernatremia on admission (serum sodium > 145mEq/L) were retrospectively analyzed. The mean age of patients was 81.1. Sepsis was observed in 77.1% of patients, of which 86.2% had dementia. This study demonstrated a positive correlation between hypernatremia on admission and the presence of sepsis. We suggest that the existence of hypernatremia should prompt clinicians to further investigate for sources of infection, especially in the elderly and patients with dementia.

An Innovative Approach to Adequate Oral Hydration in an Inpatient Geriatric Psychiatry Unit

Suboptimal hydration status and dehydration are problems that often exacerbate comorbid conditions in geriatric patients. At a Veterans Administration Hospital, it was observed that suboptimal hydration status in Veterans hospitalized in the geriatric psychiatry unit was a contributing factor in the worsening of their psychiatric and medical conditions. A quality improvement project was chartered to improve hydration in this group of patients. Using a three-pronged intervention approach (i.e., providing flavored water, providing larger cups, and increasing the prompting by nurses for patients to drink more), the project was successful. The goal was to increase average daily fluid intake by 125 mL; the result was an increase of 700 mL. This project has been sustained and the interventions have also benefitted non-geriatric psychiatry in-patients. [Journal of Psychosocial Nursing and Mental Health Services, 57(4), 15-20.].

Catatonic Stupor in Schizophrenic Disorders and Subsequent Medical Complications and Mortality

OBJECTIVE

Although catatonia can occur secondary to a general medical condition, catatonia itself has been known to lead to various medical compolications. Although case reports on the association of catatonia with subsequent medical complications have been documented, no comprehensive large-scale study has been performed. To investigate specific medical complications after catatonia, we conducted a retrospective cohort study of specific medical complications of schizophrenia patients with catatonia.

METHODS

The 1719 schizophrenia inpatients in our study were categorized into two groups: the catatonia group, i.e., those who exhibited catatonic stupor while they were hospitalized, and the noncatatonia group, i.e., those who never exhibited catatonic stupor. Differences between the two groups in the occurrence of subsequent medical complications were examined using linear and logistic regression analyses, and models were adjusted for potentially confounding factors.

RESULTS

The catatonia group had an increased risk for mortality (odds ratio = 4.8, 95% confidence interval = 2.0-10.6, p < .01) and certain specific medical complications, i.e., pneumonia, urinary tract infection, sepsis, disseminated intravascular coagulation, rhabdomyolysis, dehydration, deep venous thrombosis, pulmonary embolism, urinary retention, decubitus, arrhythmia, renal failure, neuroleptic malignant syndrome, hypernatremia, and liver dysfunction (all p values < .01, except for deep venous thrombosis, p = .04 in the multiple linear regression analysis).

CONCLUSIONS

Catatonic stupor in schizophrenia substantially raises the risk for specific medical complications and mortality. Hyperactivity of the sympathetic nervous system, dehydration, and immobility, which are frequently involved in catatonia, might contribute to these specific medical complications. In catatonia, meticulous care for both mental and medical conditions should be taken to reduce the risk of adverse medical consequences.

Recommendations for active correction of hypernatremia in volume-resuscitated shock or sepsis patients should be taken with a grain of salt: A systematic review

Background:

Healthcare-acquired hypernatremia (serum sodium >145 mEq/dL) is common among critically ill and other hospitalized patients and is usually treated with hypotonic fluid and/or diuretics to correct a “free water deficit.” However, many hypernatremic patients are eu- or hypervolemic, and an evolving body of literature emphasizes the importance of rapidly returning critically ill patients to a neutral fluid balance after resuscitation.

Objective:

We searched for any randomized- or observational-controlled studies evaluating the impact of active interventions intended to correct hypernatremia to eunatremia on any outcome in volume-resuscitated patients with shock and/or sepsis.

Data sources:

We performed a systematic literature search with studies identified by searching MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, Index-Catalogue of the Library of the Surgeon General’s Office, DARE (Database of Reviews of Effects), and CINAHL and scanning reference lists of relevant articles with abstracts published in English.

Data synthesis:

We found no randomized- or observational-controlled trials measuring the impact of active correction of hypernatremia on any outcome in resuscitated patients.

Conclusion:

Recommendations for active correction of hypernatremia in resuscitated patients with sepsis or shock are unsupported by clinical research acceptable by modern evidence standards.

Effect of osmolality on erythrocyte rheology and perfusion of an artificial microvascular network

Plasma sodium concentration is normally held within a narrow range. It may however vary greatly under pathophysiological conditions. Changes in osmolality lead to either swelling or shrinkage of red blood cells (RBCs). Here we investigated the influence of suspension osmolality on biophysical properties of RBCs and their ability to perfuse an artificial microvascular network (AMVN). Blood was drawn from healthy volunteers. RBC deformability was measured by osmotic gradient ektacytometry over a continuous range of osmolalities. Packed RBCs were suspended in NaCl solutions (0.45, 0.6, 0.9, 1.2, and 1.5 g/dL), resulting in supernatant osmolalities of 179 ± 4, 213 ± 1, 283 ± 2, 354 ± 3, and 423 ± 5 mOsm/kg H2O. Mean corpuscular volume (MCV) and mean corpuscular hemoglobin concentration (MCHC) were determined using centrifuged microhematocrit. RBC suspensions at constant cell numbers were used to measure viscosity at shear rates ranging from 0.11 to 69.5s(-1) and the perfusion rate of the AMVN. MCV was inversely and MCHC directly proportional to osmolality. RBC deformability was maximized at isosmotic conditions (290 mOsm/kg H2O) and markedly decreased by either hypo- or hyperosmolality. The optimum osmolality for RBC suspension viscosity was shifted toward hyperosmolality, while lower osmolalities increased suspension viscosity exponentially. However, the AMVN perfusion rate was maximized at 290 mOsm/kg H2O and changed by less than 10% over a wide range of osmolalities. These findings contribute to the basic understanding of blood flow in health and disease and may have significant implications for the management of osmotic homeostasis in clinical practice.