Dehydration + Dementia Flashcards
How to assess for dehydration
CRT
JVP
Skin turgor
Radial pulse
BP
Mucus membranes
HS
Breath sounds
Ascites - shifting dullness
Peripheral edema
Reasons for admission that can increase fluid requirements
Trauma
Febrile illness and sepsis
Burns
Surgical patients may need additional volume secondary to bleeding, drainage and third-space fluid losses.
Gastrointestinal losses (e.g. vomiting, diarrhoea)
Polyuria
Medical conditions that can affect fluid balance
Renal disease, congestive cardiac failure
Qs to ask/ details in hx regarding hydration
Bleeding from any source
Vomiting: frequency, volume, presence of blood
Stools: frequency, volume, presence of blood
Fever and diaphoresis
Urine output: colour and volume
Pre-syncope/syncope
Presence of thirst
Eating and drinking status (e.g. oral fluids, nil by mouth, receiving IV fluid therapy)
Symptoms of fluid overload (e.g. shortness of breath, orthopnoea, paroxysmal nocturnal dyspnoea, leg swelling)
Is the patient on a fluid restriction for another medical condition (e.g. heart failure)?
How to measure JVP
Position pt at 45 angle
Turn head to left
Look for IJV between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid
Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV (in healthy individuals, this should be no greater than 3 cm).
Causes of raised JVP
Fluid overload - HF, CKD
Pulmonary HTN
Right-sided heart failure
Tricuspid regurgitation
Constrictive pericarditis
Management of dehydration
ORS first
4 As of dementia
Amnesia
Agnosia
Aphasia
Apraxia
Sx of dementia
Decline in >1 cognitive domain: complex attention, learning + memory, language, executive function, perceptual-motor, social cognition
ADLs: dressing, eating, ambulation, toileting, hygiene, shopping, housework, food prep, managing meds
Ix
TSH, B12, CBC, creat, lytes, calcium, albumin, syphilis
MMSE
Types + features of each
AD: gradual onset, short term memory loss
Frontotemporal: behavioural problems, reduced executive function
Vascular: abrupt, step wise decline, CV RF
Lewy body: fluctuating cognition, EPSE, visual hallucinations
Non-pharmacotherapy rx for dementia
Assess competency
Discuss advanced care planning (will, power of attorney, advanced directives)
Safety ($, driving, stove, wandering)
Lifestyle (mediterranean diet, smoking cessation, Tai chi)
Supports (Alzheimers society)§
Rx for dementia: AD, frontal, vascular, lewy body
ECG prior to treatment
AD: Donepezil, rivastigmine or galantamine
Frontotemporal: SSRI
Vascular: cholinesterase inhibitors (Donepezil) or NDMA (memantine)
Lewy Body: Rivastigmine
Sx of dehydration
Increased thirst
Decrease urine/sweating/tears
Weight loss
Altered mental status, lethargy, irritability
Degrees of dehydration (% volume loss, signs, management)
Mild (3-5% volume lose) - Absent clinical signs
Home-based treatment
Moderate (6-9% volume loss) - Tachycardia, orthostatic hypotension, decreased skin turgor, dry mucous membranes, irritability, delayed capillary refill, deep respirations, possible decreased urine output/tearing and sunken fontanelle
ORT (eg. Pedialyte, Enfalyte, breastmilk) x 1 hour, re-assess
If concerned, see treatment for severe
Severe (≥10% volume loss) - “Near-shock” hypotension, lethargy, altered mental status, delayed capillary refill, cool/mottled extremities, tachypnea
Requires aggressive isotonic fluid resuscitation to prevent tissue injury
20-40mL/kg IV NS over one hour
Consider labs (concern if pH < 7.32, bicarb ≤ 17 mEq/L)
Indications for IVF
Inability for oral intake (mental status, ileus)
Inability to administer ORT (eg. no caregiver)
Persistent vomiting
Electrolyte abnormalities where ORT cannot be monitored
Fluid calculation for kids, what fluid to use
1-10kg = 4 x Wt (kg) mL/hr
>10-20kg = 40 + 2 x (Wt over 10kg) mL/hr
>20kg = 60 + 1 x (Wt over 20kg) mL/hr
Max of 100mL/hr
Can use D5NS
Parkland formula
Fluid required in first 24h = 4mLx weight (kg) x BSA (%)
Half in 8h, rest in 16h
9% each arm, 18% each leg, 18% front torso, 9% head
what bolus amount for kids
20ml/kg bolus then 4-2-1 maintenance
investigations for dehydration
weight, serum glucose, sodium, urea, creatinine, potassium, eGFR
causes of dehydration
meningitis, PNA, cholera, gastroenteritis, sepsis, abuse/ neglect, meds, DKA
elderly pt w/ diarrhea - causes
acute ischemic bowel, obstruction, diverticulitis, appendicitis, neoplasm
RF for C diff
healthcare associated, older age, immunocomprised, previous c diff infection, recent antibiotics esp fluoroquinlones
C diff rx
vanco PO
IBS rx
antispasmodics, antidepressants, truberzi, lubiprostone, linaclotide
Ibsrela
Ways to prevent dementia
lose weight, increase activity, stop smoking, reduce alcohol, manage lipids + BP, cognitive training
Risk reduction in dementia
med diet, physical exercise, fruit + veggies, >5hrs sleep, maintain social engagement
What tools to use for acute confusion/ agitation?
4AT + Confusion assessment method
Dementia vs mild cognitive impairment
dementia = loss in function
5 domains of cognition
5Ws - who, what, why, when, where = WHO you are (personality), WHAT you say (language), WHERE you go (visuo-spatial), WHY you do things (judgement), WHEN you remember (memory)
Imaging for ?dementia - what and when
3T MRI head - if last scan was >2 yrs ago
What conditions should prompt you to assess for competency
TBI, psych illness, neurocognitive dz, cognitive aging, delirium
What condition presents with falls and a slow vertical gaze?
Progressive supranuclear palsy
What condition presents with a symmetrical tremor and does not improve with L dopa?
Multiple system atrophy
Levodopa class
dopamine precursor
Alternatives to levodopa for PD
dopamine agonists (pramipexole), rotigotine patch, apomorphine pen-injector (warn about impulse control disorders e.g. gambling), MAO inhibitors
Sx of dementia
Decline in >1 cognitive domain: complex attention, learning + memory, language, executive function, perceptual-motor, social cognition
ADLs: dressing, eating, ambulation, toileting, hygiene, shopping, housework, food prep, managing meds
