Question: Hi My father has a pacemaker installed since last 17yrs. He is fine. Last 2 yrs, his kidneys have weakened (Creatinine 3.9, K+ 5.0, Heamoglobin 9.5). His BP is normal. We are keeping his net consumption of water to less than 1.5litres/day. Lately (2days) he is becoming a bit forgetful (perhaps Vascular Dementia, with slight tiredness walking, and some tremor). Please suggest on how we should take care of him, especially on his diet and any emergency measures.

Thank you for your prompt reply, Dr. Saumya Mittal. (I sent you (this) reply before in different words, but it doesn't show in my inbox, hence re-typing it to you) I am indeed getting worried about his dementia, which I worry being a early symptom of heart attack or stroke (which I pray it is not). His limbs don't appear to be stiff, we'll monitor a few more days, and let you know. He can move well. Tremors are not constant at all. He seems to shake (only fingers/arms) when he is about to sit, or just getting up, especially with heavier loads. He seems to initiate movement fine, but we'll keep a check. He never had diabetes (checked 30-Jan-2014). His blood-pressure remains in check (130/85 Jan-30-2014). We have a device to monitor it. His kidney is also deteriorating solely due to age (as confirmed by an earlier visit to a nephrologist in 2012). He has normal urine and stool. He sleeps well. He has some edema now. He has slight swelling on his feet, can wear shoes, and can walk fine. His swelling in feet persists for days, goes down, and then comes back. May I ask why we should restrict fruits (due to potassium ? ) ? We are currently strictly restricting fruits, with a very occasional serving of very less amount (3 grapes or berries etc.) Is it because of the potassium ? Is it the same reason for leafy vegetables ? Can you provide us clear numbers (maximum and minimum limits of intake) for proteins, potassium, sodium, carbohydrates, fats, iron etc. ? This will give us a clear metric for his diet. The range will help us understand, whether we are over-restricting. He seems to be a bit sedentary. We insist he walks a bit (3 rounds of 500ft per day, with a guardian). Please let us know if this is OK/too-much/too-little. His dementia became a bit pronounced, when he woke-up after an afternoon-nap, and was unable to recollect where he was. He seemed to settle down after sometime, seemed to be able to recollect better. Should there be a restriction on the amount he sleeps ? Any advice on his daily activities ? We have given him anti-pneumonia vaccine. We are trying to give him anti-influenza vaccine. He has a slight cough (say 4 rounds of throat clearing in a day, no temperature). He lives amidst grand-children, who have runny nose. Overall all there seems no disease/infection. Just the increase in dementia since the last 2 days. Please suggest the diet/lifestyle details as requested above. And let us know of any other care he needs. Regards, XXXXX

Thanks for your response. He has become a bit more weak, he has to be held firmly and taken to the bathroom. His urine, stool seems fine, and surprisingly regular. He has become more forgetful, and his speech a bit slurred. Seemingly he can follow instructions, but cannot express properly. He was given thyroxin and lacix tablets, 1 day, which we have halved. We gave him some sugar solution, which reduced his tremors. We did some tests done. Attached report. Please advise Electrolyte (mmol/L): Sodium: 136 (134-144) Potassium: 4.8 (3.5-5.2) Chloride: 105 (97-108) Carbon Dioxide: 16 (19-28) LOW Creatinine: Creatinine: 4.72 (0.76-1.27) HIGH eGFR If NonAfrican: 15 (> 59) LOW In addition: Blood Glucose level (fasting, 03/11/2014, 8:30am): 132 mmol/L He can no longer stand or walk on his own. In addition he pants when he walks slowly, holding my hand. Seemingly he can sit for a while, but prefers to lie down and sleeps. He finds it difficult to recollect things just told to him. But more importantly has slurred speech (although comprehensible and meaningful) and seemingly finds it difficult to form a chain of thought and speak it. Sometimes he seems repititive, and sometimes he answers with a delay. Often he prefers to nod. His blood pressure measurements are very normal: Date 03/10/2014 Time: 2:45 pm Blood pressure: 112/70 (pulse 68); 108/68 (pulse 69) Please advise, whether we should let him have more rest, or try to keep him a bit active. For example, should we hold him and take him to the bathroom for morning chores, or arrange for bed-pan ans sponging in bed. Is there any vitamin supplement etc. that could lower his weakness (or weakness like behavior). Are you sensing, this seems to be an emergency ? Is this a sign of a stroke, or an urgent need for dialysis ? Please advise, explaining all the possibilities you suspect, understanding very well that you have limited information, and are not seeing my father in person.