Potentially inappropriate medication with syndrome of inappropriate antidiuretic hormone secretion and gastrointestinal bleed in an older adult presenting as a psychiatric emergency

Abstract

Geriatric patients are commonly exposed to multimorbidity, polypharmacy, and potentially inappropriate medication use, with prevalence increasing over time. We seek to illustrate this risk to older adults through a case report of an older woman presenting with irritability to psychiatric emergency services in the context of potentially inappropriate medication use. On evaluation, the irritability was found to be associated with hip pain due to osteoarthritis and gastric irritation due to the use of analgesics, antacids, and other micronutrient supplements. She was diagnosed with analgesic-induced syndrome of inappropriate antidiuretic hormone production with dilutional hyponatremia and hypochloremia, iatrogenic upper gastrointestinal mucosal ulceration with melena and anemia due to blood loss, analgesic-induced coagulation disorder, acute kidney injury, impending hepatic injury, and hyponatremia-induced second-degree atrioventricular block. She recovered with treatment rationalization, pain management, and supportive care. We wish to highlight that an innocuous presentation such as increased irritability in the absence of a mental illness in an older adult may often overlie multimorbidity and potentially inappropriate medication use. We would also like to use this case report to illustrate the barriers to comprehension and compliance that may occur in geriatric patients, with the need for frequent pharmacological assessments including prescription checks and pill counts.