What is the best course of action for an 82-year-old lady with generalized severe depression, adrenal insufficiency, on oral cortisone and Lustral (sertraline), who is bedridden, sleeps excessively, and has hyponatremia?

From the Guidelines

The best course of action for this 82-year-old lady is to urgently address her hyponatremia, which is likely contributing to her excessive sleepiness and worsening depression, by adjusting her cortisone dosage and considering alternative treatments for her depression and hyponatremia. Given her complex medical condition, including adrenal insufficiency and severe depression, a comprehensive approach is necessary. Her current treatment with oral cortisone and sertraline (Lustral) should be reviewed, particularly considering the potential for SSRIs like sertraline to cause or worsen hyponatremia in elderly patients 1. The management of her hyponatremia should follow guidelines that recommend treating hyponatremia when serum sodium is lower than 130 mmol/L, although the exact threshold for treatment can vary depending on the clinical context 1. Considering her bedridden state and excessive sleepiness, a geriatric psychiatrist should evaluate her depression treatment, potentially adjusting the sertraline dose or considering an alternative antidepressant like mirtazapine 7.5-15mg at bedtime, which could help with both sleep regulation and appetite. Additionally, physical therapy consultation is essential to prevent complications of being bedridden, including pressure ulcers and further deconditioning, and a nutritional assessment should be performed to ensure adequate intake of nutrients and electrolytes. This approach is supported by the need to manage hyponatremia carefully, especially in patients with complex medical conditions, and to consider the potential benefits and risks of different treatments, including vaptans for hyponatremia, although their use would need to be carefully considered in the context of her overall medical condition 1. Given the complexity of her condition and the need for careful management of her medications and electrolyte balance, consultation with relevant specialists, including endocrinology for her adrenal insufficiency, is crucial 1.

From the FDA Drug Label

Hyponatremia may occur as a result of treatment with SSRIs and SNRIs, including sertraline. In many cases, this hyponatremia appears to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Cases with serum sodium lower than 110 mmol/L have been reported. Elderly patients may be at greater risk of developing hyponatremia with SSRIs and SNRIs Symptoms may include: headache, weakness or feeling unsteady, confusion, problems concentrating or thinking or memory problems

The patient is an 82-year-old lady with generalized severe depression, adrenal insufficiency, on oral cortisone and Lustral (sertraline), who is bedridden, sleeps excessively, and has hyponatremia with a blood sodium level of 121.

• The patient's hyponatremia and excessive sleep may be related to the sertraline treatment, as it can cause hyponatremia due to SIADH.
• Discontinuation of sertraline should be considered in patients with symptomatic hyponatremia and appropriate medical intervention should be instituted.
• Given the patient's complex medical condition, including adrenal insufficiency and severe depression, it is essential to weigh the benefits and risks of continuing sertraline treatment.
• A conservative approach would be to closely monitor the patient's sodium levels, mental status, and overall condition, while considering alternative treatments for depression that may be more suitable for this patient.
• Consultation with a geriatrician or a psychiatrist with experience in treating elderly patients with complex medical conditions may be beneficial in determining the best course of action 2.

From the Research

Patient Assessment and Diagnosis

• The patient is an 82-year-old lady with generalized severe depression, adrenal insufficiency, on oral cortisone and Lustral (sertraline), who is bedridden, sleeps excessively, and has hyponatremia with a blood sodium level of 121 3.
• The patient's hyponatremia is a significant concern, as it can cause cognitive impairment, gait disturbances, and increased rates of falls and fractures 3.
• Adrenal insufficiency is characterized by inadequate glucocorticoid production, and patients can present with an insidious onset of symptoms or acutely in adrenal crisis, which requires prompt recognition and treatment 4.

Management of Hyponatremia

• The approach to managing hyponatremia should consist of treating the underlying cause, and clinicians should categorize patients according to their fluid volume status (hypovolemic hyponatremia, euvolemic hyponatremia, or hypervolemic hyponatremia) 3.
• Urea and vaptans can be effective treatments for the syndrome of inappropriate antidiuresis and hyponatremia in patients with heart failure, but have adverse effects 3.
• Severely symptomatic hyponatremia is a medical emergency, and US and European guidelines recommend treating it with bolus hypertonic saline to reverse hyponatremic encephalopathy 3.

Considerations for Adrenal Insufficiency and Hyponatremia

• Glucocorticoid deficiency, due to central/secondary adrenal insufficiency, is a key differential diagnosis for syndrome of inappropriate antidiuresis (SIAD), as it presents with a similar biochemical picture of euvolemic hyponatremia and inappropriate urinary concentration 5.
• The underlying mechanisms for the development of hyponatremia in glucocorticoid deficiency are impaired renal water handling and increased plasma concentrations of arginine vasopressin (AVP) despite hypo-osmolality 5.
• Endocrine disorders, including adrenal deficiency and hypothyroidism, are uncommon causes of hyponatremia, but primary adrenal insufficiency (i.e. Addison's disease) may be recognized by clear hall-marks of the disease, such as pigmentation, salt craving, hypotension, and concomitant hyperkalemia 6.

Monitoring and Assessment

• Nurses should consider additional assessments of pain, level of consciousness, and urine output, as part of routine patient assessment, in addition to the traditional five vital signs 7.
• Regular monitoring for features of under- and over-replacement is essential during follow-up for patients with adrenal insufficiency 4.