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Electrolyte and salt disturbances in older people: causes, management and implications

Part of: Bespoke shallow archive Weizmann

Published online by Cambridge University Press:  01 May 2008

Roy L Soiza ,
Graeme E Hoyle  and
Melvin PW Chua
Roy L Soiza*
Affiliation:
Department of Medicine for the Elderly, Woodend Hospital, Aberdeen, UK
Graeme E Hoyle
Affiliation:
Department of Medicine for the Elderly, Woodend Hospital, Aberdeen, UK
Melvin PW Chua
Affiliation:
Department of Medicine for the Elderly, Woodend Hospital, Aberdeen, UK
*
Address for correspondence: RL Soiza, Department of Medicine for the Elderly, Woodend Hospital, Eday Road, Aberdeen AB15 6XS, UK. Email: [email protected]
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Extract

Salt and electrolyte disturbances are commonly encountered in older patients. A sound understanding of the underlying physiological and pathological mechanisms underpinning the predisposition of older people to the common electrolyte imbalances can help clinicians minimize their considerable associated morbidity and mortality. This review focuses on the more common and clinically relevant salt and electrolyte disorders of older people. The epidemiology, causes, symptoms, diagnosis and treatment of hyponatraemia, hypernatraemia, hyperkalaemia, hypokalaemia and calcium and phosphate imbalance in old age are covered from a clinician's perspective.

Type
Clinical geriatrics
Information
Reviews in Clinical Gerontology , Volume 18 , Issue 2 , May 2008 , pp. 143 - 158
Copyright
Copyright © Cambridge University Press 2009

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References

1Smith, DM, McKenna, K, Thompson, CJ. Hyponatraemia. Clin Endocrin 2000; 52: 667–78.CrossRefGoogle ScholarPubMed
2Fegan, G, Begley, J. Hyponatraemia in the elderly. CME Geriatr Med 2005; 7: 76–85.Google Scholar
3Hoyle, GE, Chua, M, Soiza, RL. Prevalence of hyponatremia in elderly patients. J Am Geriatr Soc 2006; 54: 1473.Google Scholar
4Kugler, JP, Hustead, T. Hyponatremia and hypernatremia in the elderly. Am Fam Physician 2000; 61: 3623–30.Google ScholarPubMed
5Johnson, AK, Thunhorst, RL. The neuroendocrinology of thirst and salt appetite: visceral sensory signals and mechanisms of central integration. Frontiers Neuroendocrinol 1997; 18: 292–353.Google Scholar
6Luckey, AE, Parsa, CJ. Fluid and electrolytes in the aged. Arch Surg 2003; 138: 1055–60.Google Scholar
7Tareen, N, Martins, D, Nagami, G et al. Sodium disorders in the elderly. J Nat Med Assoc 2005; 97: 217–24.Google Scholar
8Miller, M. Fluid and electrolyte homeostasis in the elderly: physiological changes of ageing and clinical consequences. Bailliere's Clin Endocrin Metabol 1997; 11: 367–87.Google Scholar
9Kumar, S, Berl, T. Sodium. Lancet 1998; 352: 220–28.CrossRefGoogle ScholarPubMed
10Tomson, CRV. Recent advances: Nephrology. Br Med J 2000; 320: 98–101.CrossRefGoogle ScholarPubMed
11Cao, L, Joshi, P, Sumoza, D. Renal salt-wasting syndrome in a patient with cisplatin-induced hyponatremia: case report. Am J Clin Oncol 2002; 25: 344–46.Google Scholar
12Cerda-Esteve, M, Cuadrado-Godia, E, Chillaron, JJ et al. Cerebral salt wasting syndrome: review. Eur J Intern Med 2008; 19: 249–54.Google Scholar
13Maesaka, JK, Gupta, S, Fishbane, S. Cerebral salt-wasting syndrome: does it exist? Nephron 1999; 82: 100–9.Google Scholar
14Turner, HE, Wass, JAH.Oxford Handbook of Endocrinology and Diabetes. Oxford University Press, Oxford, 2002.Google Scholar
15Yeates, KE, Singer, M, Morton, AR. Salt and water: a simple approach to hyponatremia. CMAJ 2004; 170: 365–69.Google Scholar
16Hoorn, EJ, Halperin, ML, Zietse, R. Diagnostic approach to a patient with hyponatraemia: traditional versus physiology-based options. Q J Med 2005; 98: 529–40.Google Scholar
17Milionis, HJ, Liamis, GL, Elisaf, MS. The hyponatraemic patient: a systematic approach to laboratory diagnosis. CMAJ 2002; 166: 1056–62.Google Scholar
18Palmer, BF, Gates, JR, Lader, M. Causes and management of hyponatremia. Ann Pharmacother 2003; 37: 1694–1702.Google Scholar
19Adrogue, HJ, Madias, NE. Primary care: Hyponatremia. NEJM 2000; 342: 1581–89.Google Scholar
20Chua, M, Hoyle, GE, Soiza, RL. Prognostic implications of hyponatremia in elderly hospitalized patients. Arch Gerontol Geriatr 2007; 45: 253–8.Google Scholar
21Renneboog, B, Musch, W, Vandemergel, X et al. Mild chronic hyponatremia is associated with falls, unsteadiness, and attention deficits. Am J Med 2006; 119: 71.e1–71.e8.Google Scholar
22Hoyle, GE, Chua, M, Soiza, RL. Volaemic assessment of elderly hyponatraemic patients. Poster presented at British Geriatrics Society Autumn Meeting, Birmingham, 23–25 April 2008.Google Scholar
23Palm, C, Reimann, D, Gross, P. The role of V2 vasopressin antagonists in hyponatremia. Cardiovasc Res 2001; 51: 403–8.CrossRefGoogle Scholar
24Molaschi, M, Ponzetto, M, Massaia, M et al. Hypernatremic dehydration in the elderly on admission to hospital. J Nutr Health Aging 1997; 1L: 156–160Google Scholar
25Passare, G, Viitanen, M, Torring, O, Winblad, B, Fastbom, J. Sodium and potassium disturbances in the elderly: prevalence and association with drug use. Clin Drug Invest 2004; 24: 535–44.Google Scholar
26Erasmus, RT, Matsua, TE. Frequency, aetiology and outcome of hypernatraemia in hospitalized patients in Umtata, Transkei, South Africa. East African Med J 1999; 76: 85–88.Google Scholar
27Snyder, NA, Feifal, DW, Arieff, AI. Hypernatremia in elderly patients: a hetereogenous, morbid and iatrogenic entity. Ann Intern Med 1987; 107: 309–19.Google Scholar
28Phillips, PA, Rolls, BJ, Ledingham, JG et al. Reduced thirst after water deprivation in healthy elderly men. N Engl J Med 1984; 311: 753–59.Google Scholar
29Kim, SW. Hypernatremia: Successful treatment. Electrolyte Blood Pressure 2006; 4: 66–71.Google Scholar
30Yamamoto, T, Harada, H, Fukuyama, J, Hayashi, T, Mori, I. Impaired arginine-vasopressin secretion associated with hypoangiotensionemia in hypernatremic dehydrated elderly patients. JAMA 1988; 259: 1039–42.Google Scholar
31Beck, LH. The aging kidney: defending a delicate balance of fluid and electrolytes. Geriatrics 2000; 55: 26–28, 31–32.Google Scholar
32Bichet, DG. Vasopressin receptors in health and disease. Kidney Int 1996; 49: 1706–11.Google Scholar
33Palevsky, PM, Bhagrath, R, Greenberg, A. Hypernatremia in hospitalized patients. Ann Inten Med 1996; 124: 197–203.CrossRefGoogle Scholar
34Ofran, Y, Lavi, D, Opher, D, Weiss, Ta, Elinav, E. Fatal voluntary salt intake resulting in the highest ever documented sodium plasma level in adults (255 mmol L−1): a disorder linked to female gender and psychiatric disorders. J Internal Med 2004; 256: 525–28.Google Scholar
35Gross, CR, Lindquist, RD, Wooley, AC et al. Clinical indicators of dehydration severity in elderly patients. J Emerg Med 1992; 10: 267–74.Google Scholar
36Chassagne, P, Druesne, L, Capet, C, Menard, JF, Bercoff, E. Clinical presentation of hypernatremia in elderly patients: a case-control study. J Am Geriatr Soc 2006; 54: 1225–30.Google Scholar
37Palevsky, PM. Hypernatremia. Semin Nephrol 1998; 18: 20–30.Google ScholarPubMed
38Long, CA, Marin, P, Bayer, AJ, Shetty, HGM, Pathy, MSJ. Hypernatraemia in an adult in-patient population. Postgrad Med J 1991; 67: 643–45.Google Scholar
39Molaschi, M, Macchione, C, Bertagna, B, Cantore, A, Ferrario, E. Fluid and electrolyte disorders in the elderly: A statistical and clinical study. Arch Gerontol Geriatr 1991; 12: 583–88.Google Scholar
40Nasar, MA, Lyle, EM. Hypokalaemia in the elderly: is it always diuretic-induced? Br J Clin Practice 1994; 48: 19–21.Google Scholar
41Epstein, M. Aging and the kidney. J Am Soc Nephrol 1996; 7: 1106–22.Google Scholar
42Bia, MJ, DeFronzo, RA. Extrarenal potassium homeostasis. Am J Physiol Renal Physiol 1981; 240: F257–68.Google Scholar
43Dunnill, MS, Halley, W. Some observations on the quantitative anatomy of the kidney. J Pathol 1973; 110: 113–21.Google Scholar
44Lindeman, RD, Tobin, J, Shock, NW. Longitudinal studies on the rate of decline in renal function with age. J Am Geriatr Soc 1985; 33: 278–85.Google Scholar
45McGreevy, C, Horan, J, Jones, D et al. A study of tubular secretory capacity in older people with hyperkalaemia. J Nutr Health Aging 2008; 12: 152–55.Google Scholar
46Musso, C, Liakopoulos, V, De Miguel, R, Imperiali, N, Algranati L. Transtubular potassium gradient: comparison between healthy old people and chronic renal failure patients. Int Urol Nephrol 2006; 38: 387–90.Google Scholar
47Weidmann, P, Demyttenaere-Bursztein, S, Maxwell, MH, DeLima, J. Effect of aging on plasma renin and aldosterone in normal man. Kidney Int 1975; 8: 325–33.Google Scholar
48Michelis, MF. Hyperkalaemia in the elderly. Am J Kidney Dis 1990; 16: 296–99.Google Scholar
49Mulkerrin, E, Epstein, FH, Clark, BA. Aldosterone responses to hyperkalemia in healthy elderly humans. J Am Soc Nephrol 1995; 6: 1459–62.Google Scholar
50Kudoh, A, Sakai, T, Ishihara, H, Matsuki, A. Renin–aldosterone in elderly patients with hyperkalaemia under anaesthesia. Eur J Anaesthesiol 1999; 16: 231–35.Google Scholar
51DeFronzo, RA, Lee, R, Jones, A, Bia, M. Effect of insulinopenia and adrenal hormone deficiency on acute potassium tolerance. Kidney Int 1980; 17: 586–94.Google Scholar
52Ikram, H. Arrhythmias, electrolytes, and ACE inhibitor therapy in the elderly. Gerontology 1987; 33: 42–47.Google Scholar
53Rosenthal, T, Shamiss, A, Holtzman, E. Dietary electrolytes and hypertension in the elderly. Int Urol Nephrol 2001; 33: 575–82.CrossRefGoogle ScholarPubMed
54Walmsley, RN, White, GH, Cain, M, McCarthy, PJ, Booth, J. Hyperkalemia in the elderly. Clin Chem 1984; 30: 1409–12.Google Scholar
55Rastergar, , Soleimani, M. Hypokalaemia and hyperkalaemia. Postgrad Med J 2001; 77: 759–64.Google Scholar
56Saggar-Malik, AK, Cappuccio FP. Potassium supplements and potassium-sparing diuretics. A review and guide to appropriate use. Drugs 1993; 46: 986–1008.Google Scholar
57Morgan, DB, Young, RM. Acute transient hypokalaemia: new interpretation of a common event. Lancet 1982; 2: 751–52.CrossRefGoogle Scholar
58Franse, LV, Pahor, M, Di Bari, M et al. Hypokalemia associated with diuretic use and cardiovascular events in the systolic hypertension in the elderly program. Hypertension 2000; 35: 1025–30.Google Scholar
59Ahee, P, Crowe, AV. The management of hyperkalaemia in the emergency department. J Accid Emerg Med 2000; 17: 188–91.Google Scholar
60Mandelburg, A, Krupnik, Z, Houri, S et al. Salbutamol metered dose inhaler with spacer for hyperkalemia. How fast? How safe? Chest 1999; 115: 617–22.Google Scholar
61Perazella, MA, Mahnensmith, RL. Hyperkalemia in the elderly: drugs exacerbate impaired potassium homeostasis. J Gen Int Med 1997; 12: 646–56.Google Scholar
62Squire, I. Can we treat heart failure effectively and maintain potassium homeostasis? A clinician's perspective. Br J Cardiol 2005; 12: 224–29.Google Scholar
63Peart, S, Barbes, GR, Broughton, PMG et al. Comparison of the antihypertensive efficacy and adverse reactions to two doses of bendrofluazide and hydrochlorothiazide and the effect of potassium supplementation on the hypotensive action of bendrofluazide: substudies of the Medical Research Council's trials of treatment of mild hypertension: Medical Research Council Working Party. J Clin Pharm 1987; 27: 271–77.Google Scholar
64Svensson, M, Gustafsson, F, Galatius, S, Hildebrandt, PR, Atar, D. How prevalent is hyperkalemia and renal dysfunction during treatment with spironolactone in patients with congestive heart failure? J Cardiac Failure 2004; 10: 297–303.Google Scholar
65Butler, JV, McAvoy, H, McEnroy, D, Mulkerrin, EC. Spironolactone therapy in older patients – the impact of renal dysfunction. Arch Gerontol Geriatr 2002; 35: 45–49.Google Scholar
66Payne, RB, Little, AJ, Williams, RB, Milner, JR. Interpretation of serum calcium in patients with abnormal serum proteins. Br Med J 1973; 4: 643–46.Google Scholar
67Quesada, JM, Coopmans, W, Ruiz, B, Aljama, P, Jans, I, Bouillon, R. Influence of vitamin D on parathyroid function in the elderly. J Clin Endocrinol Metab 1992; 75 (2): 494–501.Google Scholar
68Lau, KH, Baylink, DJ. Vitamin D therapy of osteoporosis: plain vitamin D therapy versus active vitamin D analog (D-hormone) therapy. Calcif Tissue Int 1999; 65: 295–306.Google Scholar
69Armbrecht, HJ, Zenser, TV, Bruns, ME, Davis, BB. Effect of age on intestinal calcium absorption and adaptation to dietary calcium. Am J Physiol 1979; 236: 769–74.Google Scholar
70Pattanaungkul, S, Riggs, BL, Yergey, AL, Vieira, NE, O'Fallon, WM, Khosla, S. Relationship of intestinal calcium absorption to 1,25-dihydroxyvitamin D [1,25(OH)2D] levels in young versus elderly women: evidence for age-related intestinal resistance to 1,25(OH)2D action. J Clin Endocrinol Metab 2000; 85: 4023–27.Google Scholar
71MacLaughlin, J, Holick, MF. Aging decreases the capacity of human skin to produce vitamin D3. J Clin Invest 1985; 76: 1536–38.Google Scholar
72Holick, MF, Matsuoka, LY, Wortsman, J. Age, vitamin D and solar ultraviolet. Lancet 1989; 2: 1104–5.CrossRefGoogle Scholar
73Silverberg, SJ, Shane, E, de la Cruz, L, Segre, GV, Clemens, TL, Bilezikian, JP. Abnormalities in parathyroid hormone secretion and 1,25-dihydroxyvitamin D3 formation in women with osteoporosis. NEJM 1989; 320: 277–81.Google Scholar
74Munson, PL, Hirsch PF. Importance of calcitonin in physiology, clinical pharmacology, and medicine. Bone Mineral 1992; 16: 162–65.Google Scholar
75Wood, RJ, Suter, PM, Russell, RM. Mineral requirements of elderly people. Am J Clin Nutr 1995; 62: 493–505.Google Scholar
76Endres, DB, Morgan, CH, Garry, PJ, Omdahl, JL. Age-related changes in serum immunoreactive parathyroid hormone and its biological action in healthy men and women. J Clin Endocrinol Metab 1987; 65: 724–31.Google Scholar
77Sahota, O, Mundey, MK, San, P, Godber, IM, Lawson, N, Hosking, DJ. The relationship between vitamin D and parathyroid hormone: calcium homeostasis, bone turnover, and bone mineral density in postmenopausal women with established osteoporosis. Bone 2004; 35: 312–19.Google Scholar
78Rudman, D, Kutner, MH, Rogers, CM et al. Impaired growth hormone secretion in the adult population: relation to age and adiposity. J Clin Invest 1981; 67: 1361–69.Google Scholar
79Ferrini, RL, Barrett-Connor, E. Sex hormones and age: A cross-sectional study of testosterone and estradiol and their bioavailable fractions in community-dwelling men. Am J Epidemiol 1998; 147: 750–54.Google Scholar
80Bassett, JH, Williams, GR. The molecular actions of thyroid hormone in bone. Trends Endocrinol Metabol 2003; 14: 356–64.Google Scholar
81Raisz, LG, Pilbeam, CC. Endocrine and Metabolic disorders. In: Evans, JG et al. Oxford Textbook of Geriatric Medicine. Oxford University Press: 2nd edition, 2000.Google Scholar
82Nagarajan, A, Suchak, N, Tank, L, Parulekar, M, Sarkar, A. Sub-optimal Vitamin D levels despite supplementation – How much is enough? J Am Geriatr Soc 2008; 56 (suppl 1): S75–76.Google Scholar
83Thomas, MK, Lloyd-Jones, DM, Thadhani, RI et al. Hypovitaminosis D in medical inpatients. NEJM 1998; 338: 777–83.CrossRefGoogle Scholar
84Gonzalez, C, Villasanta, U. Life-threatening hypocalcemia and hypomagnesemia associated with cisplatin chemotherapy. Obstet Gynecol 1982; 59: 732–34.Google Scholar
85Macefield, G, Burke, D. Paraesthesiae and tetany induced by voluntary hyperventilation. Increased excitability of human cutaneous and motor axons. Brain 1991; 114: 527–40.Google Scholar
86Tambyah, PA, Ong, BK, Lee, KO. Reversible Parkinsonism and asymptomatic hypocalcemia with basal ganglia calcification from hypoparathyroidism 26 years after thyroid surgery. Am J Med 1993; 94: 444.Google Scholar
87Meyer, T, Ruppert, V, Karatolios, K, Maisch, B. Hereditary long QT syndrome due to autoimmune hypoparathyroidism in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy syndrome. J Electrocardiol 2007; 40: 504–9.Google Scholar
88Cooper, MS, Gittoes, NJ. Diagnosis and management of hypocalcaemia. Br Med J 2008; 336: 1298–1302.Google Scholar
89Newman, EM, Bouvet, M, Borgehi, S, Herold, DA, Deftos, LJ. Causes of hypercalcemia in a population of military veterans in the United States. Endocr Pract 2006; 12: 535–41.Google Scholar
90Khosla, S, Atkinson, EJ, Melton, LJ, Riggs, BL. Effects of age and estrogen status on serum parathyroid hormone levels and biochemical markers of bone turnover in women: a population-based study. J Clin Endocrinol Metab 1997; 82: 1522–27.Google Scholar
91Rothschild, BM. Paget's disease of the elderly. Compr Ther 2000; 26 (4): 251–54.Google Scholar
92Cheng, CJ, Chou, CH, Lin, SH. An unrecognized cause of recurrent hypercalcemia: immobilization. South Med J 2006; 99: 371–74.Google Scholar
93Lamy, O, Burckhardt, P. Hypercalcemia of malignancy: diagnosis and treatment options. Am J Can 2002; 1: 277–92.Google Scholar
94Weisinger, JR, Bellorin-Font, E. Magnesium and phosphorus. Lancet 1998; 352: 391–96.Google Scholar
95Weiss-Guillet, EM, Takala, J, Jakob, SM. Diagnosis and management of electrolyte emergencies. Best Pract Res Clin Endocrinol Metab 2003; 17: 623–51.Google Scholar
96Armbrecht, HJ, Gross, CJ, Zenser, TV. Effect of dietary calcium and phosphorus restriction on calcium and phosphorus balance in young and old rats. Arch Biochem Biophys 1981; 210: 179–85.Google Scholar
97Sorribas, V, Lotscher, M, Loffing, J et al. Cellular mechanisms of the age-related decrease in renal phosphate reabsorption. Kidney Int 1996; 50: 855–63.Google Scholar
98Kagansky, N, Levy, S, Koren-Morag, N, Berger, D, Knobler, H. Hypophosphataemia in old patients is associated with the refeeding syndrome and reduced survival. J Intern Med 2005; 257: 461–68.Google Scholar
99Larsson, L, Rebel, K, Sorbo, B. Severe hypophosphate – a hospital survey. Acta Medica Scan 1983; 214: 221–23.Google Scholar
100Haglin, L, Burman, LA, Nilsson, M. High prevalence of hypophosphataemia amongst patients with infectious diseases. A retrospective study. J Int Med 1999; 246: 45–52.Google Scholar
101Barak, V, Schwartz, A, Kalickman, I, Nisman, B, Gurman, G, Shoenfeld, Y. Prevalence of hypophosphatemia in sepsis and infection: the role of cytokines. Am J Med 1998; 104: 40–47.Google Scholar
102Bellorin-Font, E, Starosta, R, Milanes, CL et al. Effect of acidosis on PTH-dependent renal adenylate cyclase in phosphorus deprivation: role of G proteins. Am J Phy 1990; 258: F1640–49.Google Scholar
103Subramanian, R, Khardori, R. Severe hypophosphatemia. Pathophysiologic implications, clinical presentations, and treatment. Medicine 2000; 79: 1–8.Google Scholar
104Machiels, JP, Dive, A, Donckier, J, Installe, E. Reversible myocardial dysfunction in a patient with alcoholic ketoacidosis: a role for hypophosphatemia. Am J Emerg Med 1998; 16: 371–73.CrossRefGoogle Scholar
105Melvin, JD, Watts, RG. Severe hypophosphatemia: a rare cause of intravascular haemolysis. Am J Hematol 2002; 69: 223–24.Google Scholar
106Taylor, BE, Huey, WY, Buchman, TG, Boyle, WA, Coopersmith, CM. Treatment of hypophosphatemia using a protocol based on patient weight and serum phosphorus level in a surgical intensive care unit. JACS 2004; 198: 198–204.Google Scholar
107Larner, AJ. Pseudohyperphosphatemia. Clin Biochem 1995; 28: 391–93.Google Scholar
108London, GM, Pannier, B, Marchais, SJ, Guerin, AP. Calcification of the aortic valve in the dialyzed patient. J Am Soc Nephrol 2000; 11: 778–83.Google Scholar
109Lemos, MM, Jancikic, ADB, Sanches, FMR et al. Pulse wave velocity – a useful tool for cardiovascular surveillance in pre-dialysis patients. Nephrol Dial Transplant 2007; 22: 3527–32.Google Scholar
110Slatopolsky, E. New developments in hyperphosphatemia management. J Am Soc Nephrol 2003; 14: S297–9.Google Scholar
111Locatelli, F, Cannata-Andia, JB, Drueke, TB et al. Management of disturbances of calcium and phosphate metabolism in chronic renal insufficiency, with emphasis on the control of hyperphosphataemia. Nephrol Dial Transplant 2002; 17: 723–31.Google Scholar