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Review

How Dietary Habits and Nutritional Deficiencies Relate to Hyponatremia in Older Adults

1
The Aga Khan Hospital, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan
2
Liaquat National Hospital, National Stadium Rd., Karachi 74800, Pakistan
3
Department of Medicine, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan
4
Department of Medicine, Good Samaritan Medical Center, 235 N. Pearl Street, Brockton, MA 02301, USA
5
Department of Medicine, St. Luke Warren Hospital, 185 Roseberry Street, Phillipsburg, NJ 08865, USA
6
Department of Medicine, University of Texas Southwestern, Dallas, TX 75390, USA
*
Author to whom correspondence should be addressed.
J. Ageing Longev. 2025, 5(1), 1; https://doi.org/10.3390/jal5010001
Submission received: 13 November 2024 / Revised: 15 December 2024 / Accepted: 21 December 2024 / Published: 24 December 2024

Abstract

:
Hyponatremia, a common electrolyte imbalance in older adults, results from physiological aging, medication use, and comorbidities, with significant implications for morbidity and quality of life. This narrative review aims to explore the impact of dietary habits and nutritional deficiencies on the development and management of hyponatremia in this population. A literature search identified relevant studies addressing the risk factors related to sodium balance, dietary intake, and nutrition. The key findings reveal that low sodium and age-related changes increase vulnerability to hyponatremia and its associated risks, including cognitive decline and falls. Nutritional strategies, such as optimizing sodium and protein intake and reducing processed food consumption, may offer preventative benefits. Future research should focus on tailored dietary interventions and establishing sodium intake guidelines specific to older adults. Implementing such strategies could improve the health outcomes and reduce the healthcare costs associated with hyponatremia in older populations.

1. Introduction

Hyponatremia is defined as a serum sodium level below 135 mEq/L and is a common occurrence in older adults [1]. Globally, an estimated 703 million people are age 65 and older. This number is expected to double by 2050, which may further strain healthcare systems [2]. The prevalence of hyponatremia is around 8% in the general population but rises sharply in older adults, particularly in hospital settings, where it can range from 15% to 30% [3]. In community-dwelling older individuals aged 75 and above, the prevalence reaches approximately 11.6% [4]. Hyponatremia is more frequently observed in patients in acute-care hospitals, critical care units, ambulatory-care settings, and geriatric populations than in the general population [1,5,6]. The prevalence of hyponatremia increases with age [7]. Its prevalence is about 18% in older adults compared to 2.98% in younger groups. The strategies for hospitalized older adults should include plans that optimize sodium balance and prevent the adverse outcomes associated with hyponatremia, such as cognitive impairment, falls, and increased morbidity [8].
This condition is of great clinical concern as it increases the risk of morbidity and mortality, cognitive decline, falls, and fractures, which significantly impair quality of life and increase healthcare costs by up to 20% [9]. This review aims to explore the relationship between dietary habits, nutritional deficiencies, and hyponatremia in older adults, summarizing the implications for clinical practice and prevention.
Sodium is critical in maintaining cellular homeostasis, fluid balance, nerve function, and circulatory pressures. The bioavailability of sodium is reduced as individuals age. Physiological changes, such as a decreased glomerular filtration rate (GFR), impaired sodium conservation, and reduced sodium bioavailability, contribute to this reduction [10]. Older adults are vulnerable to hyponatremia due to factors such as malnutrition, chronic diseases, and polypharmacy. The presence of impaired dietary intake, especially if low in sodium and protein consumption, increases the risk of hyponatremia. This is evident in conditions such as “tea and toast” syndrome. The syndrome results from an insufficient intake of key nutrients, which results in sodium depletion due to a fluid imbalance [1].
The clinical consequences of hyponatremia in older adults are significant. Hyponatremia impacts cognitive function and may result in delirium. In the hospital setting, this could result in an increased length of hospital stay, increasing the risk of institutionalization, functional dependence, and mortality [11]. Therefore, understanding the role of dietary habits and nutritional deficiencies in developing hyponatremia is needed to develop effective prevention and management strategies tailored to this vulnerable population.

2. Methods

This narrative review was conducted to explore the relationship between dietary habits, nutritional deficiencies, and the incidence of hyponatremia in older adults. The aim was to provide a comprehensive understanding of the topic considering the diverse sources available in the MedSurg literature, focusing on clinically relevant insights. A comprehensive literature search was conducted using PubMed, focusing on articles published in peer-reviewed journals. Key words included “hyponatremia”, “older adults”, “dietary sodium”, “nutritional deficiency”, “sarcopenia”, and “fluid balance”. Additional searches were performed using terms related to “frailty” and “malnutrition” to ensure the inclusion of studies addressing broad aspects of hyponatremia in older populations. Our approach focused on summarizing findings from clinically significant studies to offer a broad perspective on how dietary and nutritional factors may impact hyponatremia. Articles were chosen based on their relevance and the insights they offered regarding the interaction between nutrition, sodium balance, and the hyponatremia risks in older adults.

3. Results

3.1. Overview of Sodium Balance and Regulation in the Body

Serum sodium is vital for maintaining fluid balance, regulating nerve and muscle cell function, and facilitating the transport of substrates across membranes [7]. Its critical roles influence hyponatremia’s acute and chronic manifestations. A rapid decrease in serum sodium within 48 h can lead to symptoms such as headaches, nausea, vomiting, and potentially progress to seizures and coma [1]. Chronic hyponatremia can manifest as fatigue, cognitive impairment, and gait deficits, leading to falls, osteoporotic fractures, and many associated symptoms [12,13,14,15,16].

3.1.1. Factors Contributing to Hyponatremia in the Older Adult

Age is an independent risk factor for hyponatremia in older adults, often due to medications, endocrinopathies, syndrome of inappropriate antidiuretic hormone secretion (SIADH), and malnutrition, and at times leading to the development of “tea and toast” syndrome [1]. Some common causes of hyponatremia are provided in Table 1.

3.1.2. “Tea and Toast” Hyponatremia

One notable example of a dietary habit leading to malnutrition and hyponatremia in older adults is “tea and toast” syndrome. Tea and toast are typically deficient in sodium, protein, and other vital nutrients. Older individuals whose primary diet consists of such consumption increase their risk of developing hyponatremia [17]. Such a dietary pattern is often observed in older adults with poor appetite, difficulty preparing meals, or limited access to diverse food sources. A “tea and toast” diet results in sodium depletion. This, in combination with excessive water intake, results in dilution of the sodium levels in the blood, creating a fluid imbalance and thus causing hyponatremia. Additionally, protein deficiency in such diets exacerbates malnutrition, contributing further to sarcopenia and frailty [18,19].

3.1.3. Hyponatremia and Falls

Hyponatremia that is symptomatic is readily diagnosed and managed. Mild chronic hyponatremia presents a more significant challenge because of its links to adverse outcomes. Hyponatremia increases the risk of falls by contributing to neurocognitive impairment, which can cause gait instability and decreased attention span [20]. This has substantial implications for geriatric care as falls are a common medical concern among older adults [21]. Falls affect 30–60% of older adults living independently in the community yearly [22]. The outcomes of such falls in older adults can include hip fractures, hospitalizations, head injuries, and the need for admission to long-term care facilities [21]. Furthermore, prospective data from the Rotterdam Study demonstrated a significant association between baseline mild hyponatremia and recent falls, as well as both vertebral and incidental non-vertebral fractures [12]. Epidemiological and experimental evidence has shown that chronic mild hyponatremia is an independent risk factor for osteoporosis as it increases bone osteoclastic activity in a hyponatremic environment [23]. Chronic mild hyponatremia is associated with extended hospital stays, functional independence, and increased mortality in individuals with chronic disease and those admitted to Intensive Care Unit (ICU) settings [12,23,24,25].

3.2. The Role of Dietary Habits in Hyponatremia

Sodium is naturally present in various foods, and its intake can vary based on dietary habits. Familiar sources of dietary sodium include processed and packaged foods, often high in added salt. Table salt, used in cooking or as a seasoning, primarily contributes to sodium intake. Additionally, sodium-rich foods include salty snacks (such as chips and pretzels), canned soups, pickles, cured meats (such as bacon, ham, and sausages), cheese, and certain condiments (like soy sauce). Some natural foods, such as shellfish, dairy products, and vegetables like beets and celery, also provide smaller amounts of sodium [26]. For older adults at risk of hyponatremia, it is important to manage the intake of these foods.

3.2.1. The Impact of Low-Sodium Diets on Older Adults

Lower dietary sodium intake amongst community-dwelling older adults was associated with poorer cognitive function, especially in those over 80 [27]. Cognitive impairments may affect executive functions, potentially impacting intermediate activities of daily living such as financial management. Given the risk of cognitive decline in older adults, even minor changes in cognitive ability because of low sodium intake could have significant health implications. Despite the known benefits of reducing dietary sodium for hypertension, the impact of hyponatremia on cognitive function underscores the need for further investigation [28,29]. Low nutritional sodium levels may negatively influence insulin regulation and the renin–angiotensin and sympathetic systems, potentially affecting cognitive function [30,31,32]. A recent study found a J-shaped relationship between sodium intake, cardiovascular disease, and mortality. Individuals consuming more than 6 g of sodium per day and those consuming less than 3 g daily were found to have an increased risk of death and cardiovascular events [33]. Although further research is required, previous studies indicate a potential J-shaped relationship between sodium intake and cognitive function in older adults [34,35,36]. In a recent study involving older adults (average age 70 ± 12 years), adding a low-dose diuretic to angiotensin II receptor blockers for hypertension management significantly lowered the serum sodium levels in individuals with low dietary salt intake [37]. As a result, reducing the dietary sodium intake to low levels may impair an individual’s ability to maintain homeostasis, which could result in cognitive changes. This is especially concerning for older adults on medications that affect sodium levels. Reduced sodium intake has also been associated with a higher risk of cardiovascular events and mortality, regardless of blood pressure levels [23,38].

3.2.2. Sodium-Rich Foods and Their Effects on Hyponatremia

Increased sodium intake elevates intra-glomerular pressure, which can contribute to or worsen chronic kidney damage, heightening the risk of progressive kidney disease [39]. High sodium intake is a recognized risk factor for developing such conditions. Specifically, in postmenopausal women in Korea [36,38], excessive sodium intake (>2000 mg) was found to lead to increased urinary excretion (>2 g/day), resulting in hypercalciuria and raising the risk of osteoporosis [40]. Additionally, excessive salt consumption has been linked to the development of hypertension [41,42] and, consequently, to a higher risk of cardiovascular disease, particularly in individuals with hypertension and older adults [23]. Lowering sodium intake has been shown to reduce both systolic and diastolic blood pressure, especially in hypertensive and normotensive individuals [41].

3.2.3. The Role of Ultra-Processed Foods in Sodium Intake

The increased availability and consumption of ultra-processed foods has contributed to higher sodium intake in the general population. This increase is beyond the recommended dietary intake of sodium. Ultra-processed foods include packaged snacks, ready-to-eat meals, processed meats, instant noodles, and fast foods. These often contain high levels of added sodium to enhance the flavor and prolong shelf life [43]. This trend is concerning for older adults who have multiple chronic conditions (MCCs) as excessive sodium intake from these foods can exacerbate hypertension, cardiovascular disease, and renal impairment.
Consumption of ultra-processed foods could lead to both hyponatremia and hypernatremia, in older adults, especially those with MCCs, especially if on multiple medications. Thus, it is crucial for dietary interventions targeting sodium management to consider reducing ultra-processed food intake while promoting whole or minimally processed foods that support healthier sodium levels and overall nutrition [43].

3.3. Nutritional Deficiencies and Hyponatremia

As people age, their metabolic and organ reserves universally decline. A diet that may be suitable for a young adult could become harmful for the same individual later in life. Failure to adjust diet and lifestyle accordingly can result in maladaptation, where the body struggles to compensate, leading to the development of various chronic conditions that are common in older adults, such as hypertension (HTN), diabetes (DM), cardiovascular disease (CVS), and chronic kidney disease (CKD) [44]. According to the Dietary Guidelines Advisory Committee (DGAC), nearly half of all American adults, approximately 117 million individuals, have one or more chronic diseases that could be prevented with dietary improvements [45]. In an aging population, diet-induced health problems have a more significant impact due to reduced adaptability in terms of age-related metabolic capacity and organ function declines. This contributes to the increased prevalence of chronic conditions like HTN, atherosclerotic vascular diseases, and CKD in older adults. Poor diets are the primary driver of the chronic disease burden in the United States. Currently, only 1% of Americans meet the criteria for ideal CVS health; 46% have HTN, around 50% have prediabetes or DM, and approximately 14% have CKD. Adjusting nutrient intake in the modern diet can mitigate the risks of maladaptation, such as acid accumulation, excessive salt intake, potassium (K+) and fiber deficiency, and dehydration, significantly improving overall health [44].
Salt and regular water are closely intertwined. The serum sodium (Na+) concentration reflects the water balance and is the primary determinant of serum osmolality. In the kidney, arginine vasopressin (AVP) and the tonicity enhancer element binding protein (TonEBP or NFAT5) work independently and together to maintain regular water absorption, maintaining the serum Na+ concentration within the 135–145 mEq/L range. AVP regulates water and retains Na+, affecting volume balance [44].
The modern diet is deficient in potassium (K+) [46]. A low or low–normal serum or plasma K+ concentration resulting from insufficient intake can stimulate kidney NH3/NH4+ production and activate the RAAS, contributing to system inflammation, protein catabolism, CKD development, and, in patients with CKD, accelerate its progression [47].
Chronic low-grade underhydration has been linked to impaired cognitive performance, reduced cognition, perceived fatigue, and a lack of energy [48]. Underhydration also increases vulnerability to suboptimal adaptation or maladaptation, leading to kidney dysfunction and other health complications, particularly during physical stress or exposure to hot climates. It is not surprising that chronic underhydration is also associated with nephrolithiasis [49], as well as an increased risk of metabolic syndrome and CKD [44,50,51]. Fortunately, studies have shown that the adverse effects of a poor diet can be minimized through dietary modification, specifically by reducing overconsumption of salt and animal products while increasing unrefined plant foods and hydration. Increasing one’s dietary intake of fruits and vegetables enhances both the base equivalents and K+ in the body fluids, associated with lower blood pressure and reduced risk of CVS diseases, including heart failure (HF) and overall mortality [23,52,53,54,55,56].

3.3.1. Protein Energy Malnutrition and Hyponatremia in the Elderly

Sarcopenia is an age-related decline in skeletal muscle mass and function [28]. The European Working Group on Sarcopenia in Older People (EWGSOP) characterizes sarcopenia as a “progressive and widespread skeletal muscle condition linked to a higher risk of undesirable consequences, such as falls, fractures, physical impairment, and mortality” [57]. Sarcopenia has an estimated prevalence of 9 to 18% in people aged sixty-five and older, increasing to 50% in those aged over eighty. Moreover, it has been postulated that, beyond 50 years of age, muscle mass is lost at an approximate rate of 1–2% per year [58]. Some of the risk factors for sarcopenia include age, female sex, history of smoking, little to no exercise, particularly endurance training, and specific nutritional deficiencies [57].
With increasing age, skeletal muscle size and number decrease, including reduced skeletal muscle precursor cells [59]. The causes of sarcopenia are multifaceted. Decreased activity among older people [59], protein-calorie malnutrition and overnutrition [19], hormonal declines such as decreased IGF-1, DHEA-sulfate, testosterone, and estrogen levels [21], and increased inflammatory biomarkers [22] are believed to be critical contributors to the development of sarcopenia. Sarcopenia results in impaired mobility, functional dependence, and increased injury episodes among older adults. Muscle atrophy and decreased muscle strength, especially in the lower limbs, contribute to an increasing incidence of falls, which may result in fractures and other disabilities [24]. Moreover, a higher incidence of functional decline and increased length of hospitalization are also reported among sarcopenic individuals. Sarcopenia has also been identified as a significant cause of mortality, particularly among those older than seventy-nine [27].
Sarcopenia has been described as a potential cause of hyponatremia in the literature. Since muscle content represents the body’s central potassium reserve, low potassium levels are observed in individuals with sarcopenia. Low potassium content leads to a shift in sodium intracellularly and an inappropriate release of antidiuretic hormone (ADH). These two mechanisms contribute to the development of hyponatremia [60]. On the other hand, hyponatremia may also lead to sarcopenia. As mild hyponatremia is frequently encountered among the geriatric population, its high propensity to cause sarcopenia makes it imperative for physicians to address the condition in a clinical setting [61]. Frailty, closely linked to sarcopenia, is related to hyponatremia, although the mechanism is not well established. Hyponatremia acts as both a causative and a prognostic factor in managing sarcopenia and frailty [58].

3.3.2. Hyponatremia-Related Deficiencies

Electrolyte abnormalities are observed in a considerable percentage of hyponatremic patients independent of the cause of hyponatremia. In one study, more than half of those patients with diuretic-induced hyponatremia exhibited at least one additional electrolyte abnormality [62]. Chronic diuretic use is frequently associated with hyponatremia, which may also be linked to reduced intracellular potassium reserves. In a small group of patients with chronic congestive heart failure, magnesium replacement alone was sufficient to correct this hyponatremia [63]. The most common disorders associated with hyponatremia include hypophosphatemia, hypokalemia, and hypomagnesemia.

3.4. Assessing Adequate Fluid Intake in Older Adults

There is no simple or universally accepted method for measuring the hydration levels in older adults [64]. For example, HF patients may need to check their daily weight, along with daily fluid intake and output, to ensure that they are not retaining excess fluid. Similarly, individuals with chronic kidney stones must monitor their hydration levels to prevent stone formation, aiming for a daily urine output of 2.5 L in adults.

3.5. Broader Risk Factors and Considerations Regarding Hyponatremia in Older Adults

Age-related physiological changes and dietary factors are key to the development of hyponatremia in older adults. The other significant factors include hydration status, physical activity, chronic disease, socioeconomic status, healthcare coverage, and education levels [1]. Inadequate hydration can lead to hypernatremia, while excessive fluid intake may cause dilutional hyponatremia, especially in individuals with impaired kidney function or HF. It is important for older adults with impaired renal function or those taking medications that affect fluid balance to maintain a balance between fluid intake and sodium levels [65].
Sedentary behavior can exacerbate sarcopenia, especially in older adults [66]. Regular physical activity, whether mild or moderate, improves circulation and supports kidney function, aiding in sodium and fluid homeostasis [67]. Chronic diseases are more common in these populations and complicate sodium balance. Medications such as diuretics and antihypertensives often increase sodium loss. Therefore, fluid management becomes challenging for older adults with MCCs.
The social determinants of health significantly impact those factors that are essential for managing hyponatremia, including access to healthcare services, nutritional counseling, and medications. Older adults from lower socioeconomic backgrounds are less likely to have access to preventative healthcare. Limited or no healthcare coverage further complicates the situation and creates barriers to medical care, including medication reconciliation and dietary consultations. This may delay the diagnosis of hyponatremia, resulting in worsening complications [68]. Older adults with lower education levels may require help understanding the steps necessary to maintain sodium balance or how medications can affect its levels [69]. Improving health education, access to health care, and providing adequate health coverage, particularly for vulnerable populations, are crucial to ensure the self-management of chronic diseases.
Inadequate intake of protein and essential nutrients contributes to conditions like sarcopenia and “tea and toast syndrome”, which exacerbate sodium imbalances and increase susceptibility to hyponatremia. Low potassium levels and sarcopenia can both be causes and consequences of chronic hyponatremia. Additionally, increased consumption of ultra-processed foods is associated with higher sodium intake and adverse health outcomes. For older adults, balancing sodium intake to prevent both hyponatremia and hypernatremia is crucial, especially given the high prevalence of HTN and CVS disease in the population. Lastly, factors such as hydration, physical activity, chronic disease management, and socioeconomic status play significant roles in the incidence and management of hyponatremia in older adults.
There is a complex interplay between dietary habits, nutritional deficiencies, and the risk of hyponatremia in older adults. While low sodium intake and specific nutritional deficiencies contribute to vulnerability, factors such as age-related physiological changes and socioeconomic influences further complicate management strategies. Figure 1 provides a summary of the factors contributing to hyponatremia, their clinical consequences, and potential strategies to address these issues.

4. Discussion: Recommendations for Managing Hyponatremia in Older Adults

The findings of this review underscore the complex relationship between dietary habits, nutritional deficiencies, and hyponatremia in older adults. The aging process introduces physiological changes, such as decreased GFR and impaired sodium conservation, that make sodium balance challenging to maintain. Coupled with common dietary patterns, like low sodium and protein intake, older adults face an increased risk of hyponatremia, leading to outcomes that range from cognitive impairment to heightened fall risk. These insights reveal the importance of viewing dietary and nutritional factors as integral components in the prevention and management of hyponatremia.
Managing hyponatremia in this population presents unique challenges. Clinicians must carefully balance sodium intake, particularly in older adults with comorbidities, such as HTN, CKD, and frailty. Polypharmacy further complicates the scenario as diuretics and antidepressants exacerbate sodium depletion. These complexities highlight the need for a nuanced approach, one that considers both dietary sodium intake and broader nutritional factors while navigating the risks associated with high sodium intake for cardiovascular health.

Screening, Diagnosis, and Management of Hyponatremia in Older Adults

Diagnosing hyponatremia in older adults includes a thorough history. The history should include an assessment of food and fluid intake, with particular attention regarding salt intake and any underlying medical conditions that may contribute to sodium imbalances, such as CHF, liver disease, and renal impairment. Hyponatremia is diagnosed by checking the serum sodium concentration. Once a diagnosis of hyponatremia is established, the underlying cause is evaluated by testing urine osmolality and other electrolytes.
The management of hyponatremia includes both the treatment of the underlying cause and the sodium imbalance itself. Increasing dietary sodium and protein can benefit patients with mild chronic hyponatremia, especially if their diet is low in sodium intake. Correcting nutritional deficiencies in people with protein malnutrition is necessary for restoring sodium balance and supporting overall health.
For patients with dilutional hyponatremia, the treatment is through fluid restriction. This is especially used for the management of patients with hyponatremia due to HF and SIADH, where water retention exacerbates sodium dilution [65]. In more severe cases, such as acute symptomatic hyponatremia, careful administration of hypertonic saline may be required under close medical supervision to avoid complications like osmotic demyelination syndrome.
The prevention of hyponatremia in older adults focuses on dietary education and modification. Older adults should be encouraged to maintain balanced sodium, protein, and fluid intake while avoiding excessive consumption of processed foods that are high in sodium. Education on the potential effects of medications, such as diuretics and psychotropic drugs that can alter sodium balance, is also crucial [1]. Regular monitoring of sodium levels in high-risk individuals, such as those with MCCs, may help to prevent the development of more severe forms of hyponatremia.
Dietary habits increase the risk of hyponatremia in older adults. Aging impacts sodium regulation due to physiological changes, like reduced GFR and decreased sodium conversation. These age-related changes are linked to an increased prevalence of hyponatremia, particularly in those with comorbidities such as kidney disease and HF. While low sodium intake is beneficial for managing HTN, it may increase the risk of cognitive decline and impair physical function in older adults. There is a J-shaped relationship between sodium levels and health outcomes, where both very high and very low sodium intake can negatively impact health, particularly in those over 80.
Future strategies in managing hyponatremia should focus on targeted dietary interventions. Emphasizing adequate sodium and protein intake while limiting ultra-processed foods may help to address the nutritional gaps that increase vulnerability to hyponatremia. Educational initiatives tailored to older adults and caregivers could enhance awareness and adherence to sodium balance guidelines, equipping them with practical strategies for dietary adjustments. An interdisciplinary approach, involving dieticians, physicians, and caregivers, is also essential, supporting personalized care that reflects each patient’s unique health status and nutritional needs.
Further research is warranted to refine sodium intake guidelines specifically for geriatric populations. Studies investigating optimal sodium thresholds could help to balance the risks of both hypertension and hyponatremia while also examining how dietary modifications impact sodium balance and overall health in frail older adults. As healthcare costs and aging-related challenges continue to grow, preventive care practices that incorporate dietary education and support may play a crucial role in mitigating the impact of hyponatremia on quality of life and healthcare systems.

5. Conclusions

This review highlights the complex relationship between dietary habits, nutritional deficiencies, and the development of hyponatremia in older adults. The aging process results in physiological changes—such as decreased GFR and impaired sodium conservation—that make sodium balance difficult to maintain. Coupled with common dietary patterns, like low sodium and protein intake, older adults are at an increased risk of hyponatremia, leading to adverse outcomes that range from cognitive impairment to higher risk of falls.
Several new issues come into light in managing hyponatremia that require further exploration in the current literature. Table 2 provides a summary of the factors contributing to hyponatremia and potential interventions. This table aims to summarize the findings for practical application in clinical settings. First, specific dietary patterns such as “tea and toast syndrome” remain underrecognized as critical contributors to hyponatremia in older adults, particularly among those with limited access to balanced diets and food insecurity. Second, the increasing prevalence of ultra-processed foods poses the risk of potentially contributing to both hyponatremia and hypernatremia, depending on the sodium content. Third, the bidirectional relationship between hyponatremia and sarcopenia—where each act as both a cause and a consequence—emerges as a novel challenge requiring targeted clinical attention. Finally, the lack of age-specific sodium intake guidelines remains a critical gap, necessitating research to balance hypertension management with the prevention of hyponatremia.
We propose developing tailored sodium intake guidelines for older adults, based on the J-shaped relationship between sodium levels and health outcomes, to provide a balanced approach to managing hypertension and hyponatremia. Nutritional screening tools and educational interventions for caregivers and clinicians can improve the early detection and management of sodium and protein deficiencies. Promoting minimally processed, nutrient-rich foods while reducing ultra-processed food consumption is a feasible dietary intervention to mitigate risks.
Future research should investigate the long-term effects of combined dietary sodium and protein optimization on outcomes related to hyponatremia. Additionally, the socioeconomic barriers to adequate nutrition and their impact on hyponatremia merit further exploration. By addressing these dietary risks and focusing on sodium and protein adequacy, healthcare providers can contribute to better health outcomes, potentially reduce hospitalizations, and improve the quality of life for older adults. These insights underscore the importance of integrating dietary and nutritional factors into comprehensive strategies for managing hyponatremia in geriatric populations.

Author Contributions

Conceptualization, N.J.; literature search and review, M.A. (Maaha Ayub), M.A. (Meher Angez), N.B.M., S.T.R., D.K. and R.F.; writing—original draft preparation, M.A. (Maaha Ayub), M.A. (Meher Angez), N.B.M., S.T.R., D.K. and R.F.; writing—review and editing, N.J. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. Flowchart: Factors Contributing to Hyponatremia and Proposed Interventions.
Figure 1. Flowchart: Factors Contributing to Hyponatremia and Proposed Interventions.
Jal 05 00001 g001
Table 1. Medications causing hyponatremia in older patients [5].
Table 1. Medications causing hyponatremia in older patients [5].
  • Medications
A.
Diuretics
Mechanism: Extracellular volume depletion and stimulation of SIADH 1
Most common agent: Thiazide diuretics and occasionally loop diuretics.
Hyponatremia caused by thiazide diuretics is frequently observed in those with hepatic disease, cardiac failure, or cancer and with polypharmacy, i.e., NSAIDs 2, SSRIs 3, or tricyclic antidepressants.
B.
Psychotropic Medications
Mechanism: Development of SIADH
  • Antipsychotic drugs: Phenothiazines, Butyrophenones
  • Benzodiazepines
  • Antidepressants: More commonly associated with SSRIs 3, SNRIs 4, and mirtazapine. Less commonly with Bupropion, Trazodone, and Tricyclic antidepressants.
C.
Antiepileptic drugs (AEDs)
Most common agents: Carbamazepine and Oxcarbazepine
Other AEDs: Eslicarbazepine, Sodium Valproate, Lamotrigine, Levetiracetam, and Gabapentin
2.
Endocrinopathies
Hypopituitarism, Hypothyroidism
A.
SIADH 1
Aging associated with increased plasma vasopressin concentration
B.
Hyperglycemia/DM 5
Diabetes induces osmotic diuresis and hypovolemic hyponatremia
3.
Tea and toast syndrome
Malnutrition in seniors due to lack of desire or inability to prepare and eat proper meals
1 Syndrome of Inappropriate antidiuretic hormone secretion (SIADH); 2 Non-Steroidal Anti-Inflammatory Drugs (NSAIDs); 3 Selective Serotonin reuptake inhibitors (SSRIs); 4 Serotonin-norepinephrine reuptake inhibitor (SNRI); 5 Diabetes Mellitus (DM).
Table 2. Key factors influencing hyponatremia in older adults.
Table 2. Key factors influencing hyponatremia in older adults.
CategoryFactorsImpactProposed Interventions
Dietary HabitsLow sodium intake
Protein deficiency
Ultra-processed foods
Increased risk of hyponatremia
Cognitive decline
Frailty and sarcopenia
Optimize sodium and protein intake
Reduce ultra-processed foods
Age-Related ChangesReduced GFR
Impaired sodium conservation
Decreased reserves
Higher susceptibility to Electrolyte imbalances
Increased morbidity
Tailored sodium and fluid guidelines
Comorbidities and MedicationsCHF, CKD, SIADHDiuretics, SSRIs, AntiepilepticsExacerbates sodium loss
Risk of falls and fractures
Regular monitoring and medication reconciliation
Socioeconomic FactorsLimited access to healthcare Lower educationDelayed diagnosis and treatmentHealth education
Improved healthcare access
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Ayub, M.; Angez, M.; Musavi, N.B.; Rehman, S.T.; Kataria, D.; Farhan, R.; Jamshed, N. How Dietary Habits and Nutritional Deficiencies Relate to Hyponatremia in Older Adults. J. Ageing Longev. 2025, 5, 1. https://doi.org/10.3390/jal5010001

AMA Style

Ayub M, Angez M, Musavi NB, Rehman ST, Kataria D, Farhan R, Jamshed N. How Dietary Habits and Nutritional Deficiencies Relate to Hyponatremia in Older Adults. Journal of Ageing and Longevity. 2025; 5(1):1. https://doi.org/10.3390/jal5010001

Chicago/Turabian Style

Ayub, Maaha, Meher Angez, Nabiha B. Musavi, Syed Tabish Rehman, Deepak Kataria, Rabeea Farhan, and Namirah Jamshed. 2025. "How Dietary Habits and Nutritional Deficiencies Relate to Hyponatremia in Older Adults" Journal of Ageing and Longevity 5, no. 1: 1. https://doi.org/10.3390/jal5010001

APA Style

Ayub, M., Angez, M., Musavi, N. B., Rehman, S. T., Kataria, D., Farhan, R., & Jamshed, N. (2025). How Dietary Habits and Nutritional Deficiencies Relate to Hyponatremia in Older Adults. Journal of Ageing and Longevity, 5(1), 1. https://doi.org/10.3390/jal5010001

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