Skip to main content
×
Home
    • Aa
    • Aa

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

  • Roy L Soiza (a1), Graeme E Hoyle (a1) and Melvin PW Chua (a1)
Abstract

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.

Copyright
Corresponding author
Address for correspondence: RL Soiza, Department of Medicine for the Elderly, Woodend Hospital, Eday Road, Aberdeen AB15 6XS, UK. Email: roy.soiza@nhs.net
References
Hide All
1Smith DM, McKenna K, Thompson CJ. Hyponatraemia. Clin Endocrin 2000; 52: 667–78.
2Fegan G, Begley J. Hyponatraemia in the elderly. CME Geriatr Med 2005; 7: 7685.
3Hoyle GE, Chua M, Soiza RL. Prevalence of hyponatremia in elderly patients. J Am Geriatr Soc 2006; 54: 1473.
4Kugler JP, Hustead T. Hyponatremia and hypernatremia in the elderly. Am Fam Physician 2000; 61: 3623–30.
5Johnson AK, Thunhorst RL. The neuroendocrinology of thirst and salt appetite: visceral sensory signals and mechanisms of central integration. Frontiers Neuroendocrinol 1997; 18: 292353.
6Luckey AE, Parsa CJ. Fluid and electrolytes in the aged. Arch Surg 2003; 138: 1055–60.
7Tareen N, Martins D, Nagami G et al. Sodium disorders in the elderly. J Nat Med Assoc 2005; 97: 217–24.
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.
9Kumar S, Berl T. Sodium. Lancet 1998; 352: 220–28.
10Tomson CRV. Recent advances: Nephrology. Br Med J 2000; 320: 98101.
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.
12Cerda-Esteve M, Cuadrado-Godia E, Chillaron JJ et al. Cerebral salt wasting syndrome: review. Eur J Intern Med 2008; 19: 249–54.
13Maesaka JK, Gupta S, Fishbane S. Cerebral salt-wasting syndrome: does it exist? Nephron 1999; 82: 100–9.
14Turner HE, Wass JAH. Oxford Handbook of Endocrinology and Diabetes. Oxford University Press, Oxford, 2002.
15Yeates KE, Singer M, Morton AR. Salt and water: a simple approach to hyponatremia. CMAJ 2004; 170: 365–69.
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.
17Milionis HJ, Liamis GL, Elisaf MS. The hyponatraemic patient: a systematic approach to laboratory diagnosis. CMAJ 2002; 166: 1056–62.
18Palmer BF, Gates JR, Lader M. Causes and management of hyponatremia. Ann Pharmacother 2003; 37: 16941702.
19Adrogue HJ, Madias NE. Primary care: Hyponatremia. NEJM 2000; 342: 1581–89.
20Chua M, Hoyle GE, Soiza RL. Prognostic implications of hyponatremia in elderly hospitalized patients. Arch Gerontol Geriatr 2007; 45: 253–8.
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.e171.e8.
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.
23Palm C, Reimann D, Gross P. The role of V2 vasopressin antagonists in hyponatremia. Cardiovasc Res 2001; 51: 403–8.
24Molaschi M, Ponzetto M, Massaia M et al. Hypernatremic dehydration in the elderly on admission to hospital. J Nutr Health Aging 1997; 1L: 156160
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.
26Erasmus RT, Matsua TE. Frequency, aetiology and outcome of hypernatraemia in hospitalized patients in Umtata, Transkei, South Africa. East African Med J 1999; 76: 8588.
27Snyder NA, Feifal DW, Arieff AI. Hypernatremia in elderly patients: a hetereogenous, morbid and iatrogenic entity. Ann Intern Med 1987; 107: 309–19.
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.
29Kim SW. Hypernatremia: Successful treatment. Electrolyte Blood Pressure 2006; 4: 6671.
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.
31Beck LH. The aging kidney: defending a delicate balance of fluid and electrolytes. Geriatrics 2000; 55: 2628, 31–32.
32Bichet DG. Vasopressin receptors in health and disease. Kidney Int 1996; 49: 1706–11.
33Palevsky PM, Bhagrath R, Greenberg A. Hypernatremia in hospitalized patients. Ann Inten Med 1996; 124: 197203.
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.
35Gross CR, Lindquist RD, Wooley AC et al. Clinical indicators of dehydration severity in elderly patients. J Emerg Med 1992; 10: 267–74.
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.
37Palevsky PM. Hypernatremia. Semin Nephrol 1998; 18: 2030.
38Long CA, Marin P, Bayer AJ, Shetty HGM, Pathy MSJ. Hypernatraemia in an adult in-patient population. Postgrad Med J 1991; 67: 643–45.
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.
40Nasar MA, Lyle EM. Hypokalaemia in the elderly: is it always diuretic-induced? Br J Clin Practice 1994; 48: 1921.
41Epstein M. Aging and the kidney. J Am Soc Nephrol 1996; 7: 1106–22.
42Bia MJ, DeFronzo RA. Extrarenal potassium homeostasis. Am J Physiol Renal Physiol 1981; 240: F25768.
43Dunnill MS, Halley W. Some observations on the quantitative anatomy of the kidney. J Pathol 1973; 110: 113–21.
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.
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.
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.
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.
48Michelis MF. Hyperkalaemia in the elderly. Am J Kidney Dis 1990; 16: 296–99.
49Mulkerrin E, Epstein FH, Clark BA. Aldosterone responses to hyperkalemia in healthy elderly humans. J Am Soc Nephrol 1995; 6: 1459–62.
50Kudoh A, Sakai T, Ishihara H, Matsuki A. Renin–aldosterone in elderly patients with hyperkalaemia under anaesthesia. Eur J Anaesthesiol 1999; 16: 231–35.
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.
52Ikram H. Arrhythmias, electrolytes, and ACE inhibitor therapy in the elderly. Gerontology 1987; 33: 4247.
53Rosenthal T, Shamiss A, Holtzman E. Dietary electrolytes and hypertension in the elderly. Int Urol Nephrol 2001; 33: 575–82.
54Walmsley RN, White GH, Cain M, McCarthy PJ, Booth J. Hyperkalemia in the elderly. Clin Chem 1984; 30: 1409–12.
55Rastergar, Soleimani M. Hypokalaemia and hyperkalaemia. Postgrad Med J 2001; 77: 759–64.
56Saggar-Malik AK, Cappuccio FP. Potassium supplements and potassium-sparing diuretics. A review and guide to appropriate use. Drugs 1993; 46: 9861008.
57Morgan DB, Young RM. Acute transient hypokalaemia: new interpretation of a common event. Lancet 1982; 2: 751–52.
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.
59Ahee P, Crowe AV. The management of hyperkalaemia in the emergency department. J Accid Emerg Med 2000; 17: 188–91.
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.
61Perazella MA, Mahnensmith RL. Hyperkalemia in the elderly: drugs exacerbate impaired potassium homeostasis. J Gen Int Med 1997; 12: 646–56.
62Squire I. Can we treat heart failure effectively and maintain potassium homeostasis? A clinician's perspective. Br J Cardiol 2005; 12: 224–29.
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.
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: 297303.
65Butler JV, McAvoy H, McEnroy D, Mulkerrin EC. Spironolactone therapy in older patients – the impact of renal dysfunction. Arch Gerontol Geriatr 2002; 35: 4549.
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.
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): 494501.
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: 295306.
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.
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.
71MacLaughlin J, Holick MF. Aging decreases the capacity of human skin to produce vitamin D3. J Clin Invest 1985; 76: 1536–38.
72Holick MF, Matsuoka LY, Wortsman J. Age, vitamin D and solar ultraviolet. Lancet 1989; 2: 1104–5.
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.
74Munson PL, Hirsch PF. Importance of calcitonin in physiology, clinical pharmacology, and medicine. Bone Mineral 1992; 16: 162–65.
75Wood RJ, Suter PM, Russell RM. Mineral requirements of elderly people. Am J Clin Nutr 1995; 62: 493505.
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.
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.
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.
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.
80Bassett JH, Williams GR. The molecular actions of thyroid hormone in bone. Trends Endocrinol Metabol 2003; 14: 356–64.
81Raisz LG, Pilbeam CC. Endocrine and Metabolic disorders. In: Evans JG et al. Oxford Textbook of Geriatric Medicine. Oxford University Press: 2nd edition, 2000.
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): S7576.
83Thomas MK, Lloyd-Jones DM, Thadhani RI et al. Hypovitaminosis D in medical inpatients. NEJM 1998; 338: 777–83.
84Gonzalez C, Villasanta U. Life-threatening hypocalcemia and hypomagnesemia associated with cisplatin chemotherapy. Obstet Gynecol 1982; 59: 732–34.
85Macefield G, Burke D. Paraesthesiae and tetany induced by voluntary hyperventilation. Increased excitability of human cutaneous and motor axons. Brain 1991; 114: 527–40.
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.
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.
88Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia. Br Med J 2008; 336: 12981302.
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.
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.
91Rothschild BM. Paget's disease of the elderly. Compr Ther 2000; 26 (4): 251–54.
92Cheng CJ, Chou CH, Lin SH. An unrecognized cause of recurrent hypercalcemia: immobilization. South Med J 2006; 99: 371–74.
93Lamy O, Burckhardt P. Hypercalcemia of malignancy: diagnosis and treatment options. Am J Can 2002; 1: 277–92.
94Weisinger JR, Bellorin-Font E. Magnesium and phosphorus. Lancet 1998; 352: 391–96.
95Weiss-Guillet EM, Takala J, Jakob SM. Diagnosis and management of electrolyte emergencies. Best Pract Res Clin Endocrinol Metab 2003; 17: 623–51.
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.
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.
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.
99Larsson L, Rebel K, Sorbo B. Severe hypophosphate – a hospital survey. Acta Medica Scan 1983; 214: 221–23.
100Haglin L, Burman LA, Nilsson M. High prevalence of hypophosphataemia amongst patients with infectious diseases. A retrospective study. J Int Med 1999; 246: 4552.
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: 4047.
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: F164049.
103Subramanian R, Khardori R. Severe hypophosphatemia. Pathophysiologic implications, clinical presentations, and treatment. Medicine 2000; 79: 18.
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.
105Melvin JD, Watts RG. Severe hypophosphatemia: a rare cause of intravascular haemolysis. Am J Hematol 2002; 69: 223–24.
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: 198204.
107Larner AJ. Pseudohyperphosphatemia. Clin Biochem 1995; 28: 391–93.
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.
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.
110Slatopolsky E. New developments in hyperphosphatemia management. J Am Soc Nephrol 2003; 14: S2979.
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.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Reviews in Clinical Gerontology
  • ISSN: 0959-2598
  • EISSN: 1469-9036
  • URL: /core/journals/reviews-in-clinical-gerontology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Metrics

Full text views

Total number of HTML views: 1
Total number of PDF views: 21 *
Loading metrics...

Abstract views

Total abstract views: 316 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 22nd October 2017. This data will be updated every 24 hours.