Chronic hyponatremia can be insidious in community living older adults. The symptoms are overlooked by family, caregivers, and others, and simply ascribed to aging, depression, and/or early dementia. Reviewing patient medication regimens, identifying those agents that can cause hyponatremia, and preparing an action plan to address findings are crucial in medication therapy management (MTM). By identifying offending medications and discontinuing or replacing them, caregivers can reverse chronic hyponatremia without hospitalization.
Here’s what to know:
What is hyponatremia? Hyponatremia is the most common electrolyte imbalance in older adults in hospitals and skilled nursing facilities (SNF).(1-3) The early symptoms of malaise, lethargy, muscle weakness, and/or confusion can rob the individual of vibrancy, activity, and social engagement. Often chronic hyponatremia is unrecognized until a blood sodium concentration of less than 130 mEq/L is found.
Why is it so common? A plethora of medications commonly prescribed for older adults can lead to hyponatremia.(4,5) Taken as single prescriptions, the individual may suffer mild hyponatremia (sodium level 130 to 134 mEq/L). However, polypharmacy with multiple medications that affect sodium homeostasis, may cause moderate to severe hyponatremia resulting in emergent visits and subsequent long hospitalizations to correct the sodium levels. A prescribing cascade adding one more agent that contributes to hyponatremia and/or an illness episode that results in changes in diet along with increased fluids (“tea and toast syndrome”) can each be the trigger for moderate to severe hyponatremia.
What happens without treatment? Moderate hyponatremia (sodium level 125 to 129 mEq/L) can lead to unrelenting headache and nausea, muscle twitching and a 4-fold increased risk of falls. (6) When sodium falls below 120 mEq/L, seizures, brain herniation, coma, respiratory arrest, and death can result. Sodium repletion is a delicate process: fluid restriction along with slow sodium administration. Too fast can cause brain swelling with permanent neurological impairment or death. Patients may recover and return to their community setting or, all too often, patients transition to a SNF for an indefinite period.(7,8)
Here’s how ActualMeds tech-enabled service makes a difference:
Doe and Lou Jones, both age 83, live in an assisted living community. Ben, an ActualMeds Pharmacist on Demand (POD), interviews them. Lou is doing well following recovery from a myocardial infarction and coronary artery bypass graft (CABG) procedure. Doe is awaiting a multi-level spinal fusion for chronic pain due to spinal stenosis and degenerative disc disease. Lou says “I am worried. You would think Doe is the one who just had a heart attack! Doe seems out of it, tired, and all around unbalanced with worse fibro symptoms. Is it aggravated by caregiving for me after 55 years together? Doe seems to eat less and less and drinks green tea all day.”
Fortunately for Doe and Lou, their PODs pharmacist uses the ActualMeds InConcert medication management system to import Doe’s medication history to review. The InConcert system from ActualMeds automates best practice medication reconciliation and medication therapy management. Along with captured Activities of Daily Living and other Social Determinants of Health (SDOH), PODs pharmacists provide care teams the right information at the right time across care settings. This medication regimen review with context can contribute to orchestration of the best possible outcomes for high-risk patients.
The ActualMeds InConcert system displays actionable drug-drug interaction risks (Medispan®) and the full suite of “Beers List” agents of medications potentially inappropriate in older adults.(5) Among the Beers List are medications that cause hyponatremia and/or the “syndrome of inappropriate antidiuretic syndrome” (SIADH). Diuretics such as HCTZ cause hyponatremia by stimulating antidiuretic hormone (ADH) thereby impairing urinary dilution while also increasing thirst and water intake. Serotonin causes SIADH in those taking SSRIs, SNRIs, and TCA antidepressants. The pain reliever tramadol, antipsychotics, and certain antiepileptics (e.g., carbamazepine and oxcarbazepine) can also cause SIADH.
All three of Doe’s current medications are flagged as “Beers” risks for hyponatremia/SIADH on the InConcert system. The pharmacist asks Doe and Lou when Doe’s symptoms started. “I’d say it was right after Thanksgiving,” says Lou. This information leads the pharmacist to suspect Doe developed SIADH when tramadol was added to her medication regimen for lumbar pain, hypertension (HCTZ) and fibromyalgia (the SNRI duloxetine).
Here’s how ActualMeds POD pharmacists take action:
The PODs pharmacist initiates an action plan to send to Doe’s prescribers showing the combined risks for hyponatremia/SIADH identified by InConcert along with a narrative of Doe and Lou’s comments. The pharmacist suggests changing the antihypertensive to one without HCTZ. He also suggests changing the pain prescription and discontinuing tramadol.
The pharmacist tells the couple “I am going to contact your doctors to let them know that you need a sodium blood test. They may change your blood pressure medication to one without the HCTZ diuretic. They may also switch your tramadol to a different pain medication that is less likely to affect your sodium levels.” The pharmacist also contacts the Registered Dietitian in the assisted living community to arrange a Medical Nutrition Therapy (MNT) consult for Doe and Lou on how to better manage Doe’s diet.
Research indicates that medication induced SIADH occurs only in those who are volume replete.(7,8) Often SIADH occurs when a new medication with that risk is added to a regimen and there is a recent increase in fluid intake. Doe may have had chronic, undiagnosed hyponatremia from the combination of her HCTZ and duloxetine. When tramadol was added Nov. 20, her symptoms of SIADH occurred about a week after and those symptoms affected her diet. The constellation of a triple medication whammy and diet changes plunged her sodium level to 129 mEq/L.
Doe’s primary care provider changed her antihypertensive to amlodipine/benazepril and switched her tramadol to acetaminophen. She was instructed to restrict her fluids and eat frequent small meals. In a week’s time, her sodium was back to 132 mEq/L. In two weeks, it was back to 135 mEq/L.
Quick action by Doe’s ActualMeds POD pharmacist and other providers prevented a fall, ED trip and hospitalization for Doe – and can help your patients too. To learn more about ActualMeds, please visit https://www.actualmeds.com/solutions.