Prevalence of Hyponatremia in Elderly Patients with Hip Fractures: A Two-Year Study

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1 Originl Pper Received: Februry 12, 2017 Accepted: August 14, 2017 Published online: August 14, 2017 Prevlence of Hypontremi in Elderly Ptients with Hip Frctures: A Two-Yer Study Rocco Aicle Domizino Trntino Nicol Mffulli, b Deprtment of Musculoskeletl Disorders, School of Medicine nd Surgery, University of Slerno, Slerno, Itly ; b Centre for Sports nd Exercise Medicine, Queen Mry University of London, Brts nd the London School of Medicine nd Dentistry, Mile End Hospitl, London, UK Significnce of the Study In this study, the prevlence of hypontremi ws high (1) in elderly ptients 65 yers with hip frctures. Since hypontremi is ssocited with significnt morbidity nd mortlity, our findings could help improve helth cre delivery by highlighting the importnce of constnt ssessment of serum sodium concentrtion during hospitl sty nd of tiloring tretment. Keywords Hypontremi Hip frcture Elderly ptients Abstrct Objective: This study investigted the prevlence of hypontremi in elderly ptients ( 65 yers old) with hip frctures. Subjects nd Methods: All records contining clinicl nd lbortory dt on the 334 elderly ptients dmitted to the Sn Giovnni di Dio e Ruggi d Argon Hospitl of Slerno, Itly, with hip frctures during 2014 nd 2015, were retrieved from the hospitl dtbse. Ptients were divided into 4 groups, ccording to their sex nd the type of hip frcture. Sodium serum concentrtions were retrieved from the medicl records. Hypontremi ws defined s the presence of t lest 1 episode of hypontremi during the hospitl sty. Results: Of 334 elderly ptients, hypontremi ws found in 64 (1). The prevlence of hypontremi ws 1 (28/157) for femle ptients with extrcpsulr proximl femorl frcture, 22% (17/79) for femle ptients with intrcpsulr proximl femorl frcture, 20% (12/60) for mle ptients with extrcpsulr proximl femorl frcture, nd 1 (7/38) for mle ptients with intrcpsulr proximl femorl frcture. Conclusion: There ws high prevlence of hypontremi in the elderly ptients with hip frctures. Hence, serum sodium concentrtions should be regulrly ssessed to prevent occurrence of hypontremi. Introduction 2017 The Author(s) Published by S. Krger AG, Bsel Hypontremi is defined s serum sodium concentrtion <135 mmol/l [1], nd is the most common electrolyte imblnce encountered in clinicl prctice. The prevlence of hypontremi increses in fril ptients, such s the elderly, hospitlized, nd periopertive ptients with frctures [2 5]. Elderly ptients with frgility E-Mil krger@krger.com The Author(s) Published by S. Krger AG, Bsel This is n Open Access rticle licensed under the Cretive Commons Attribution-NonCommercil-4.0 Interntionl License (CC BY-NC) ( pplicble to the online version of the rticle only. Usge nd distribution for commercil purposes requires written permission. Nicol Mffulli, MD, MS, PhD, FRCS (Orth) Centre for Sports nd Exercise Medicine, Queen Mry University of London Brts nd the London School of Medicine nd Dentistry, Mile End Hospitl 275 Bncroft Rod, London E1 4DG (UK) E-Mil qmul.c.uk

2 frctures re prticulrly susceptible to hypontremi becuse of their impired physiology, multiple comorbidities (such s hypocortisolism, hypothyroidism, heptic cirrhosis, renl disese, nd congestive hert filure), polyphrmcy (e.g., ntihypertensives, ntidepressnts, nd ntiepileptics), hospitliztion, periopertive fluid restrictions, nd homeosttic stress from the frcture itself nd the subsequent surgery [6]. These ptients re lso t higher risk of the complictions of hypontremi such s brin injury, the min result of cute symptomtic hypontremi nd ssocited with significnt morbidity nd mortlity [7, 8]. Severe hypontremi (i.e., serum sodium concentrtion <125 mmol/l), if unrecognized in its first stges nd left untreted, hs high rte of mortlity; for this reson, n ccurte clinicl ssessment must be mde, focusing on fluid sttus, exmining the potentil etiology, nd conducting the pproprite investigtions [9]. In pproximtely 50% of ptients, chronic hypontremi results from inpproprite ntidiuretic hormone secretion [10]. Chronic mild hypontremi is usully symptomtic nd is trditionlly regrded s benign [11]. However, it is ssocited with lower bone minerl content nd density in nerly ll regions of the hip, with more pronounced losses in the trochnteric nd femorl neck regions [12]. It cn lso led to osteoporosis, bnorml git ptterns, cognitive impirment, bone deminerliztion, respirtory filure, noncrdiogenic pulmonry edem, flls, nd frctures [2, 13 16]. Compred to normontremic individuls, hypontremic individuls re known to hve longer time from dmission to surgery nd n incresed length of index hospitl dmission [17]. Hip frctures re most serious consequence of flls in the elderly, leding to significnt risk of morbidity nd mortlity [18]. Furthermore, the combintion of old ge nd flls is common cuse of dmission to nursing home [19]. Age is nonmodifible risk fctor, but flls re preventble [20, 21]. Therefore, the im of this study ws to investigte the prevlence of hypontremi in elderly ptients with hip frctures, focusing on the differences in prevlence between femle nd mle ptients with extr- or intrcpsulr proximl femorl frctures. Subjects nd Methods All records contining clinicl nd lbortory informtion bout ptients dmitted with hip frcture to the Sn Giovnni di Dio e Ruggi d Argon Hospitl of Slerno, Itly, in 2014 nd 2015, were retrieved from the hospitl dtbse. Inclusion criteri were Tble 1. Number of hypontremic ptients in ech group, the prevlence of hypontremi, nd comprison of prevlence cross groups Ptients with hypontremi/ group, n Femle ECPFF 28/ Femle ICPFF 17/79 22 Mle ECPFF 12/60 20 Mle ICPFF 7/38 18 Totl popultion 64/ Femle ECPFF/ICPFF Mle ECPFF/ICPFF Mles/femles ECPFF/ICPFF Comprison of prevlence cross groups, p vlue Prevlence of hypontremi, % ECPFF, extrcpsulr proximl femorl frcture; ICPFF, intrcpsulr proximl femorl frcture. n ge of 65 yers nd the occurrence of hip frctures (extr- nd intrcpsulr proximl femorl frctures). Bsed on the bove criteri, totl of 334 ptients were identified in the dtbse. They were divided into 4 groups ccording to sex nd type of femorl neck frcture: 157 femle ptients with extrcpsulr proximl femorl frcture, 79 femle ptients with intrcpsulr proximl femorl frcture, 60 mle ptients with extrcpsulr proximl femorl frcture, nd 38 mle ptients with intrcpsulr proximl femorl frcture. This division ws mde to evlute the multiple spects of the possible link between hypontremi nd different types of hip frcture. After visul check of the pre- nd postsurgicl rdiogrphs to confirm the dignosis, nd the serum sodium concentrtions mesured upon dmission, on the dy before surgery, on the dys fter surgery (clculted s men of vlues of the dys until dischrge), nd every 48 h therefter until hospitl dischrge, were nlyzed. Serum sodium concentrtions were determined by indirect potentiometry using the SYNCHRON System (Beckmn Instruments, Bre, CA, USA). The mesuring equipment ws clibrted with known stndrds ech week, using the protocol suggested by the mnufcturer. The mens of the serum sodium concentrtions t the time points listed bove were clculted using the verge feture of Microsoft Excel. The prevlence of hypontremi ws clculted using the sort nd filter nd conditionl formtting fetures of Microsoft Excel. For the purposes of this investigtion, hypontremi ws defined s serum sodium concentrtion <135 mmol/l [1] tht occurred t lest once during ptient s hospitl sty from dmission to dischrge. The χ2 test with the Ytes correction ws performed to compre prevlence cross groups. Sttisticl significnce ws set t p < Aicle/Trntino/Mffulli

3 Tble 2. Men serum sodium concentrtion nd prevlence of hypontremi in ech group At dmission Presurgery dy Postsurgery dys At dischrge Serum sodium concentrtion, mmol/l study popultion femle ECPFF femle ICPFF mle ECPFF mle ICPFF ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 3.3 Men totl 139 ± ± ± ± ± 3.4 At dmission Presurgery dy Postsurgery dys At dischrge Prevlence of hypontremi study popultion femle ECPFF femle ICPFF mle ECPFF mle ICPFF 13% 14% Men totl 11% 11% 17% 0% 1 ECPFF, extrcpsulr proximl femorl frcture; ICPFF, intrcpsulr proximl femorl frcture. Expressed s men ± SD. 5% Results Of the 334 ptients, there were more femles ( n = 236, 71%) thn mles ( n = 98, 2), with rtio of 2.4: 1. In both femle nd mle ptients, there were more extrcpsulr proximl femorl frctures, 157/236 (67%) nd 60/98 (61%), respectively thn intrcpsulr proximl femorl frctures, 79/236 (33%) nd 38/98 (3), respectively. Overll, the prevlence of hypontremi in the totl popultion ws 1 (64/334). There were no sttisticlly differences cross groups ( Tble 1 ). There were no sttisticlly significnt differences between the dmission nd the presurgery groups (29/327, due to missing dt vs. 34/262, due to missing dt; p = 0.164), or between the postsurgery nd hospitl dischrge groups (14/235, due to missing dt vs. 14/137, due to missing dt; p = 0.215). A sttisticlly significnt difference ws found between the pre- nd- postopertive groups (34/262, due to missing dt vs. 14/235, due to missing dt; p = 0.043). The highest vlue of men serum sodium concentrtion (140.5 mmol/l) ws during the hospitl dischrge phse in femles with extrcpsulr proximl femorl frcture group, nd the lowest vlue (138.3 mmol/l) ws during the presurgery phse in the femle intrcpsulr proximl femorl frcture group ( Tble 2 ). There ws decrese in the men serum sodium concentrtion in ll groups between dmission nd the presurgery phse but n increse from the presurgery to the postsurgery phse, nd further increse from the postsurgery to the hospitl dischrge phse (except in mles with intrcpsulr proximl femorl frcture) ( Tble 2 ). Discussion In this study, the prevlence of hypontremi in ptients with proximl femorl frctures ws high. The prevlence of hypontremi ws 1 for femle ptients with extrcpsulr proximl femorl frcture, 22% for femle ptients with intrcpsulr proximl femorl frcture, 20% for mle ptients with extrcpsulr proximl femorl frcture, nd 1 for mle ptients with extrcpsulr proximl femorl frcture. The men 1 prevlence of hypontremi in the totl popultion ws lower thn the 2 reported by Cumming et l. [22]. This discrepncy could be due to the type of popultion studied. It is noteworthy tht the study popultion in Cumming et l. [22] ws not restricted to femorl frctures, but included ll types of frgility frctures in elderly ptients. In our study, there ws 9.4% prevlence of hypontremi in elderly ptients with intrcpsulr frcture upon dmission, lower thn the 22% reported by Cervellin et l. Hypontremi in Elderly Hip-Frcture Ptients 453

4 [23]. This discrepncy could be due to the lrger number of ptients in their study ( n = 491 vs. n = 334 in ours). Mild chronic hypontremi should not be viewed s benign condition [11] becuse it is cused by multiple comorbidities or phrmcologic tretments (e.g., ntihypertensives, ntidepressnts, nd ntiepileptics), nd cn led to severl pthologies nd even deth, both in nd out of hospitl [6 8, 24 26]. Even mild hypontremi in the elderly should be considered risk fctor for flls [21]. Since the seril ssessment of serum sodium concentrtion is simple, inexpensive, nd rpid biochemicl test, it seems resonble to suggest tht clinicins should investigte the presence of hypontremi in ll elderly ptients tking medictions potentilly involved in the pthogenesis of hypontremi, nd pln n effective clinicl mngement through wreness of the dverse effects of certin drugs on serum sodium levels [27]. The tretment of mild hypontremi remins n open question, especilly in the elderly. Severl lines of evidence suggest tht rpid correction of chronic hypontremi my be ssocited with severe complictions, especilly serious neurologic injury in ptients undergoing fluid restriction [28]. For the generl mngement of chronic hypontremi, Spsovski et l. [29] recommend to stop nonessentil fluids, medictions, or other fctors tht cn led to hypontremi. They lso suggest cusespecific tretment nd to not use tretment with the sole im of incresing serum sodium concentrtion. A sfer strtegy my be represented by the dministrtion of new clss of drugs, the vsopressin ntgonists or vptns, which re cpble of correcting hypontremi in different clinicl conditions [30], though dt on mjor clinicl outcomes re still conflicting nd somewht lcking [31]. Finlly, it is uncler whether treting hypontremi improves ptient outcomes. Even if it is decided to tret hypontremi, it is often uncler which tretment option is most pproprite [29]. The limittions of this study were missing dt becuse in mny ptients serum sodium concentrtion ws not systemticlly ssessed during the hospitl sty, nd lso the lck of dt on the etiology of hypontremi in ech ptient. Conclusion In this study, the prevlence of hypontremi ws 1, so it ws indeed frequent occurrence in the elderly ptients with hip frctures. Serum sodium concentrtions should be routinely ssessed in elderly ptients with hip frctures nd the hypontremi corrected ccordingly. Acknowledgements The uthors would like to thnk Loredn Viscido, the wrd sister in chrge of the Division of Trumtology of Sn Giovnni di Dio e Ruggi d Argon Hospitl of Slerno, for her technicl ssistnce. References 1 Moritz ML, Ayus JC: The pthophysiology nd tretment of hypontremic encephlopthy: n updte. Nephrol Dil Trnsplnt 2003; 18: Gnkm Kengne F, Andres C, Sttr L, et l: Mild hypontremi nd risk of frcture in the mbultory elderly. QJM 2008; 101: Soiz RL, Tlbot HSC: Mngement of hypontremi in older people: old threts nd new opportunities. Ther Adv Drug Sf 2011; 2: Tmbe AA, Hill R, Livesley PJ: Post-opertive hypontremi in orthopedic injury. Injury 2003; 34: Updhyy A, Jber BL, Mdis NE: Incidence nd prevlence of hypontremi. Am J Med 2006; 119(7 suppl 1):S30 S35. 6 Soiz RL, Hoyle GE, Chu MP: Electrolyte nd slt disturbnces in older people: cuses, mngement nd implictions. Rev Clin Gerontol 2008; 18: Ayus JC, Wheeler JM, Arieff AI: Postopertive hypontremic encephlopthy in menstrunt women. Ann Intern Med 1992; 117: Ayus JC, Achinger SG, Arieff A: Brin cell volume regultion in hypontremi: role of sex, ge, vsopressin, nd hypoxi. Am J Physiol Renl Physiol 2008; 295:F619 F Clyton JA, Le Jeune IR, Hll IP: Severe hypontremi in medicl in-ptients: etiology, ssessment nd outcome. QJM 2006; 99: Ellison DH, Berl T: Clinicl prctice. The syndrome of inpproprite ntidiuresis. N Engl J Med 2007; 356: Ayus JC, Moritz ML: Bone disese s new compliction of hypontremi: moving beyond brin injury. Clin J Am Soc Nephrol 2010; 5: Kruse C, Eiken P, Verblis J, et l: The effect of chronic mild hypontremi on bone minerl loss evluted by retrospective ntionl Dnish ptient dt. Bone 2016; 84: Renneboog B, Musch W, Vndemergel X, et l: Mild chronic hypontremi is ssocited with flls, unstediness, nd ttention deficits. Am J Med 2006; 119: 71.e1 e8. 14 Verblis JG, Brsony J, Sugimur Y, et l: Hypontremi-induced osteoporosis. J Bone Miner Res 2010; 25: Hoorn EJ, Rivdeneir F, vn Meurs JBJ, et l: Mild hypontremi s risk fctor for frctures: the Rotterdm Study. J Bone Miner Res 2011; 26: Ayus JC, Arieff AI: Pulmonry complictions of hypontremic encephlopthy. Noncrdiogenic pulmonry edem nd hypercpnic respirtory filure. Chest 1995; 107: Aicle/Trntino/Mffulli

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