Question: Dear Health Care Magic Cardiologists,

My mother, Meli Whinston, is 91 years old and has Alzheimer's. She had five children. She has always been very athletic, healthy, and vigorous, with a dozen plus world records in weightlifting as a XXXXXXX She holds over half of the club records in the Decathlon events at the local prestigious health club in XXXXXXX age groups. She looks 65-70 years of age.

However, Meli does not tolerate medications well, and never has, even as a healthy adult. (She has had strong reactions to Norco, Tylenol, Metoprolol, and Atenolol). She is what they call, "medication sensitive." She had liver problems during the second half of her last two pregnancies, which self-resolved after birth. There are liver problems on both sides of the family. The liver aspect may explain her medication sensitivity and sometimes unusual responses. I tell people that "Meli has a C-minus liver."

Meli has asymptomatic Atrial Fibrillation. She likes to go for walks, and they are good for her, and she knows it. She likes ping pong and vigorously hitting a balloon with hands, legs, head, or foam bat.

Meli was on Diltiazem 360 mg for A-Fib, to reduce the BP and thus reduce the HR, thereby reducing the workload on her heart. Diltiazem started in early February 2016. While on Diltiazem 360 mg, her resting BP averaged about 119/79 to 120/80 and her resting HR averaged about 88-89 bpm. Local area family was concerned that the side effects of the Diltiazem were debilitating and possibly that the reduction in BP / HR was minimal. Local family asked if the Diltiazem could be very carefully reduced, on a trial basis, and on a step-by-step basis, to see if the Diltiazem was actually needed. Perhaps a lower dose would suffice, or maybe none at all was needed.

The dose of Diltiazem was decreased (starting 11/22/16) step-by-step to 240 mg, 180 mg, 120 mg, and as of 2/18/18, reduced to zero. Side effects reduced with each step down. Most important, Meli's resting BP / HR did not rise a little as the Diltiazem was slowly reduced (as one would expect). Meli's resting BP / HR actually decreased when off of Diltiazem. Now that she has been off Diltiazem for almost 9 months, her resting BP / HR for the last about 5 months average a resting BP of 110/75 and a resting HR of 81. (These reductions in Meli's BP / HR are statistically significant by two-tailed T-Test). It looks like Meli is an exception, outlier, and contrarian with respect to the average-bell-curve response to Diltiazem.

Meli has a court-appointed guardian. In February 2017, during the reduction of Diltiazem, Meli's guardian reported that her cardiologist wanted Meli's water / fluid intake to be limited to 2 liters or 67 ounces per day. This seemed odd as sufficient water intake is usually considered very important for the elderly. The elderly may lose cognitive function if dehydrated, and may get dizzy and lightheaded and fall. In Meli, when dehydrated, she gets what I call the F.I.A.C. symptoms: Fussiness, Irritability, Agitation, Anger, Anxiety, and Confusion.

Even worse, when dehydrated enough, Meli loses her sense of thirst, and does not feel thirsty. This is a vicious circle. In this state, she greatly needs water but has no natural thirst for it. Finally we will get enough water in her, and all of the FIAC symptoms disappear, and she is sweet lovable Meli again. It is like magic. I have explained this to the guardian, and "they" have recently allowed the water intake to go up to a maximum of 75 ounces. The problem is that the caregivers are afraid to give ample water during the day, out of fear of someone going over the 75 ounce limit at the end of the day, and everyone getting in big trouble. In short, Meli just isn't getting enough water.

I am trained in engineering math, pre-med science, advanced statistics, psychology with honors (with Phi Beta Kappa honors), a year of graduate school in clinical psychology, and research techniques in psychology. I have read the online medical literature re A-Fib and water / hydration. Dehydration is actually a cause of A-Fib. Hydration is a treatment for A-Fib. The assisted living staff with decades of experience tell me that they never restrict water in an A-Fib elderly patient unless the congestive heart failure is so severe (fluid build up in the lungs) that the patient cannot lie down horizontally. Meli is certainly not in this category. She has only a very little pitting edema on her shin bone.

I spoke with a middle-aged RN nurse at an elderly care facility and he said that he has never heard of restricting water / fluid in the elderly unless the patient is on dialysis. He says that the local family needs to talk to the cardiologist re this issue of limiting water in the elderly, and get an explanation for why it is ordered. Everyone I talk to concurs.

Worse, when agitated or similar (due to dehydration), Meli is visibly under a very huge stress. But stress causes adrenaline. And adrenaline worsens A-Fib. Even if there is indeed a valid medical reason for limiting water in an elderly A-Fib patient, in this particular patient (Meli), due to her agitation-type response to dehydration, it seems to local family that the damage to Meli's heart due to the dehydration-induced-agitation is far worse than the damage to her heart due to a little extra water in an A-Fib patient. Everyone I talk to concurs on this, too.

Meli's primary care doctor recently did an annual exam on 8/30/18. She says Meli "has renal insufficiency - try to make sure she drinks 2 liters water per day" (2 liters is 67 ounces). The primary doctor is saying at least 67 ounces of water a day, and the cardiologist is saying no more than 67 or 75 ounces a day. This contradiction is another reason we need an explanation. Further, an online review of renal insufficiency says that dehydration is a cause of renal insufficiency. We wonder, has the limiting of fluid to 67 ounces all along caused or worsened the renal insufficiency?

We need a cardiology specialist advice on restricting water in an elderly A-Fib patient, and if restricted, when it is called for. Is fluid restriction called for here? Is Meli's stress-causing agitation response to insufficient water a reason to not limit water in this particular patient, even if limiting water in an A-Fib patient is advised in general? (Meli has requested DNR and no end-of-life medical heroics).

There is a guardian involved. Local family cannot just contact the doctor. The recent 67 ounce fluid limit, with not-to-exceed a maximum of 75 ounces, was signed by a RN, not the cardiologist. My suspicion is that there may be a failure of communication involved, and that it may be with the guardian and RN, not the cardiologist (we met her once and she seemed very helpful and competent). The local family's interest is just to get good care for Meli, not to blame anyone.

Please, can you inform me of proper fluid administration in an elderly A-Fib patient such as Meli above? I apologize for the length of this background information. (I have continuously subscribed to the Specialist Service for a year and this is only the second time I have asked a question. Further, I am happy to cover an additional fee due to my length here). I can provide additional info if needed. Thank you.

Thank you very much for your advice and consideration. Sincerely, XXXXXXX Whinston (Meli's son). November 16, 2018.

Dear Dr. Ilir Sharka, Thank you very much for your very helpful answer. We will talk to the guardian and hopefully be allowed to talk to the cardiologist, and see what can be done to allow more water. It would be helpful if I could say if you are board certified in Cardiology, and if you are US certified, as that may help get a discussion going. I hope you can understand. Again, thank you very much. Sincerely, XXXXXXX Whinston 11/19/18.