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 implement a multifaceted approach addressing hyponatremia, chronic kidney disease (CKD), fall prevention, and potential cardiac conditions, with a focus on gradual correction of sodium levels, optimization of CKD management, and implementation of fall prevention strategies, as recommended by the American Geriatrics Society (AGS) and supported by the US Preventive Services Task Force recommendation statement 1.

To address the patient's hyponatremia, correction should be done gradually, aiming for no more than 6-8 mEq/L increase in 24 hours to avoid osmotic demyelination syndrome, using fluid restriction (typically 1-1.5L daily) for mild cases or 3% hypertonic saline for severe symptomatic cases. CKD management should include optimizing blood pressure control with ACE inhibitors or ARBs at appropriate doses adjusted for kidney function, while monitoring potassium and creatinine.

Fall prevention measures should include:

• Physical therapy evaluation
• Home safety assessment
• Appropriate assistive devices
• Balance exercises
• Vitamin D supplementation of at least 800 IU per day, as recommended by the AGS and the American Academy of Family Physicians 1
• Management of postural hypotension, including gradual position changes, compression stockings, adequate hydration within fluid restrictions, and possibly midodrine 2.5-10mg three times daily if severe

Cardiac conditions require targeted treatment, such as beta-blockers like metoprolol 25-100mg twice daily for arrhythmias, or ACE inhibitors, beta-blockers, and carefully dosed diuretics for heart failure, with medication adjustments accounting for kidney function. Orthostatic hypotension management is crucial, and the patient's medication regimen should be reviewed to minimize or withdraw psychoactive or other medications that may contribute to falls, as recommended by the AGS 1.

The patient's recent fall and history of falls highlight the importance of a comprehensive approach to fall prevention, including regular medical care to ensure optimized hearing and vision, and medication management, as outlined by the National Institute on Aging and the AGS 1. By addressing these interconnected issues, the patient's risk of falls, morbidity, and mortality can be minimized, while improving their overall quality of life.

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 a goal of increasing the serum sodium level by 4-6 mEq/L within 1-2 hours, but not exceeding a correction limit of 10 mEq/L within the first 24 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.

Laboratory Results and Monitoring

• The patient's laboratory results show hyponatremia, with a sodium level of 129 mEq/L, and CKD, with an eGFR of 40 mL/min/1.73m² 3.
• The patient's potassium, chloride, and CO2 levels are within normal limits, but the BUN and creatinine levels are elevated, consistent with CKD 3.
• Close monitoring of the patient's electrolyte levels, renal function, and fluid status is necessary to guide management and prevent complications 3, 4, 5.