What is the best course of action for a patient with hyponatremia, chronic kidney disease (CKD), and a history of falls, who has recently experienced a fall and may have underlying cardiac conditions, such as arrhythmias or heart failure, and potential orthostatic hypotension?

From the Guidelines

The best course of action for this patient is to undergo a comprehensive evaluation and management plan that addresses hyponatremia, chronic kidney disease, fall risk, and potential cardiac conditions, with a focus on careful correction of hyponatremia, cardiac evaluation, medication review, and fall prevention measures. The patient's presentation with hyponatremia, CKD, and a history of falls requires a multifaceted approach to management. According to the American Geriatrics Society (AGS) recommendations 1, detecting a history of falls is fundamental to a falls reduction program, and the AGS recommends asking all older adults once a year about falls. The patient's hyponatremia should be corrected carefully at a rate not exceeding 6-8 mEq/L in 24 hours to avoid osmotic demyelination syndrome, typically using fluid restriction and possibly 3% hypertonic saline depending on severity and symptoms.

Key Components of Management

• Cardiac evaluation, including ECG, echocardiogram, and possibly Holter monitoring to identify arrhythmias or heart failure that may contribute to falls
• Medication review to identify and modify drugs that may worsen orthostatic hypotension, such as diuretics, antihypertensives, or alpha-blockers
• CKD management should be optimized with nephrology consultation, adjusting medications for renal function and monitoring electrolytes closely
• Fall prevention measures should include physical therapy evaluation, home safety assessment, appropriate assistive devices, and balance training
• Medication reconciliation is crucial, potentially reducing or eliminating medications that increase fall risk The Geriatric Emergency Department Guidelines 1 also emphasize the importance of a comprehensive assessment, including history, physical examination, and diagnostic tests, to identify the underlying cause of the fall.

Additional Considerations

• The patient's medication list should be reviewed to identify potential contributors to falls, such as psychoactive or other medications, and minimized or withdrawn as necessary
• The patient's home environment should be assessed for safety hazards and modified as needed to reduce fall risk
• The patient should be evaluated for vitamin D deficiency and supplemented if necessary, as vitamin D supplementation has been shown to reduce fall risk in older adults 1

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations Midodrine should be used with caution in patients with renal impairment, with a starting dose of 2.5 mg Renal function should be assessed prior to initial use of midodrine.

The patient has a history of falls, hyponatremia, and chronic kidney disease (CKD). Considering the patient's orthostatic hypotension and renal impairment, midodrine may be a potential treatment option, but it should be used with caution due to the risk of supine hypertension.

• The patient's eGFR is 40, indicating renal impairment, which requires a starting dose of 2.5 mg of midodrine.
• The patient's hyponatremia and CKD should be carefully monitored while using midodrine.
• Regular blood pressure monitoring is necessary to minimize the risk of supine hypertension.
• Lifestyle alterations, such as elevating the head of the bed, may help control supine hypertension.
• The patient should be advised to report symptoms of supine hypertension immediately and to discontinue the medication if supine hypertension persists 2, 2, 2.

From the Research

Patient Assessment and Diagnosis

• The patient is a 92-year-old male with a past medical history of hypertension, presenting after an unwitnessed fall with hyponatremia (sodium level of 129 mEq/L) and chronic kidney disease (CKD) 3.
• The patient's symptoms and signs are consistent with mild hyponatremia, including weakness and a history of falls 3, 4.
• The patient's CKD and hyponatremia may be contributing to his increased risk of falls and fractures 3.

Management of Hyponatremia

• The management of hyponatremia should be based on the underlying cause and the patient's fluid volume status (hypovolemic, euvolemic, or hypervolemic) 3, 4, 5.
• For patients with euvolemic hyponatremia, treatment may include restricting free water intake or using salt tablets or intravenous vaptans 4, 5.
• Hypertonic saline may be reserved for patients with severely symptomatic hyponatremia, with the goal of increasing the serum sodium level by 4-6 mEq/L within 1-2 hours 3, 6.

Considerations for CKD and Falls

• Patients with CKD are at increased risk of electrolyte imbalances, including hyponatremia, and may require closer monitoring and management 3, 7.
• The patient's history of falls and CKD may require a multidisciplinary approach to management, including physical therapy, occupational therapy, and medication management to reduce the risk of future falls 3.

Treatment Approach

• The treatment approach for this patient should prioritize correcting the underlying cause of hyponatremia, managing CKD, and reducing the risk of future falls 3, 4, 5.
• The patient's sodium level should be monitored closely to avoid overly rapid correction, which can cause osmotic demyelination syndrome 3, 4, 6.