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Relation Between Dehydration and Short Term

Memory Function Impairment in College


Students
Annisa Bunga Nafara, S.Ked
dr Mochamad Bahrudin, Sp.S
dr. Annisa’ Hasanah, M.Kes

Muhammadiyah Malang University


Faculty of Medicine
Introduction
• Dehydration is the loss of body fluid from all compartments caused by
the water intake is less that the need of fluid/loss of fluid from body
(Guyton, 2012). Loss 1-3% of body fluid is indicated as mild
dehydration. (Indonesian Health Minister, 2011).
• 60,9% of college student in Gadjah Mada University indicated an
involuntary dehydration (penggalih 2013)
• Short term memory (STM) is the ability to memorize information for
seconds or minutes in the certain time. (Syaifuddin, 2009)
• recent study held in Malang showed that decrease of STM function
also happen on adolescent and adult in high significant number
(Tantomi, 2013)
CNS
disease

Head
Congenital
trauma
anomaly
history

Memory
function
psychologic age

Sleep
nutrition
behavior
Glutamat
activation

Hypocampus cortex

AMPA NMDA

Influks Blokcage Ca+ canal


Na+ by Mg+

Depolar Blockage freed by


ization depolarization

increase Ca+
concentration

Neurotransmitter
release

(Despopoulos, 2003).
Cause of dehydration
1. Inadequate fluid consumption
• No access of clean food and water
• Inability to eat and drink without assistance
• Inability to chew and swallow
• Loss of appetite
2. Excess body fluid loss
• vomit
• diarrhea
• malabsorbtion
• bleeding
• Fluid drainage (wounds, nasogastric)

(Johnson, 2008)
Effect of dehydration to theBbrain
1. Blood and Serum (Biller, 2015).
• Decrease of hematocrite (HCT) counts
• Increase of Osmolality by 0,67%.
• Decrease of K + concentration
• Decrease glucose serum
• decrease H2O level by 1, 63%
2. Brain Tissue (Biller, 2015)

Dehydration

Lower H20 level in


the brain

hyperosmolarity

Cell shrinking

Changes of brain volume

Hypothalamus/
Cerebral cortex White matter
thalamus
3. Brain circulation and vascularization
decline blood volume and reduction of blood flow
velocity in internal carotid artery, middle cerebral
artery, dan common carotid artery. (Trangmar, et al.
2015)

carotid artery system (80% of brain


circulation).(Bahrudin, 2012)

front and upper brain Lateral brain


(anterior cerebral artery) (middle cerebral artery)
4. Astrocyte density in corpus callosum
lower astrocyte density in corpus callosum by 34%.
Decrease ratio of astrocyte and glia cell by 57,5%.
(Haro, 2015).

Astrocyte carry the function to maintain blood brain barrier, ion level, nutrition, solutted gasses concentration,
and neurotransmitter balance
(Bahrudin, 2012)
5. Cerebrospinal fluid

Dehydration

Lower ventricle volume


(ventricle 4th)

Lower CSF level

(Streitbu¨rger, et al. 2012).

Function of CSF: distributing nutrition, and chemical impulse (Bahrudin, 2012)


Inducing Dehydration
1. Heat stress (Lieberman, 2012)
2. Physical activity
• Treadmill 40 minutes, speed: 5,6 Km/H loss 1% of body fluid
(Lieberman, 2012)
• Ergocycle, 120 minutes loss 3% of body fluid (Trangmar, 2015)
• Marathon running 12,5 rounds in soccer yard 5 km for maximum
45 minute. (Prasetya, et al, 2015)
3. Dehydration Induced Anorexia (Haro, 2015)
4. Diuretic drugs (furosemid 40mg) (Armstrong, 2012)
Dehydration assessment
1. Orthostatic dehydration: Lower systole pressure
>20mmHg, diastole>10mmHg (Penggalih, 2013)
2. Increase Heart Rate (≥ 120x/menit) (Penggalih, 2013)
3. Acute body weight loss (≥ 0,5%) (Putriana, 2014)
4. Sweat loss (≥ 645 ml, with formula BW1-BW2+Fluid
consumption during exercise- urine Volume output)
(Putriana, 2014)
5. Urine density by urine specific gravity(≥ 1.010 g/dl)
(Putriana, 2014)
Short memory function assessment
• Forward and backward digit span (Wechsler Intelligence Scale)
• Clock Drawing Test (CDT)
• Comprehensive Computerized Six-Task Cognitive Test Battery version
1.2.4
• Code test
• WAIS digitspan Forward used to assess Phonological
loop, which has role to generate conclusion and
storing verbal information
• WAIS digitspan backward used to assess central
excecutive function, which has role in concentration
ability, collecting information, keep auditoric
information, transform and manipulate the
information

(Suarez, 2016)
Fluid intake↓ Fluid loss↑

Mild dehydration

Volume and blood flow Disturbance of nutrition and


velocity in carotid system↓ electrolyte balance in serum

Oxygen supply↓ Nutrition supply↓ glucose ↓ Hyperosmolari Influx Na- and K+


-ty of extra ↓
cellular fluid
Synapses
astrocyte, cerebral cortex
Cell shrinking depolarization↓
and hippocampus function↓
CSF↓, neuron Release
-psychological depression
volume↓ neurotransmitter
-anxiety
(glutamate)↓
-head trauma
-neurological disease
- >50 years old Short term memory function Note
-nutrition intake ↓ impairment : observed
-fatigue : not observed
-alcohol : confounding
-cortisol level in brain : cause
Methods
Variable

independent • Dehydration

dependent
• Short term
memory function
• Sample size
Slovin formula

n= Sample size
N= population size (medical student of UMM, male)
d= expected presition (10%)

= 61,2 (62 samples)


Inclusion criteria
1. Third year medical student of UMM, male.
2. Ideal body weight (body mass index = 18,5-24,9)
3. Physical and psychological healthy
4. 20-25 years old
5. Willing to be a volunteer
Exclusion criteria
1. Have history of chronic disease such as renal dysfunction (kidney
stone, glomerulonefritis)
2. Alcohol consumption habit
3. Have history of neurological disease (alzheimer, epilepsi, delirium,
skizophrenia, head trauma)
4. Psychological disturbance
5. Malnutrition
Drop out criteria
1. Experience disturbing symptom during exercise (such as headache,
dizziness, nausea, vomit)
2. Not willing to continue the experiment
Operation definition
1. Dehydration
induction: physical exercise by treadmill for 40 minute, speed 5,6 km/h,
grade 5%, room temperature 27,6 ±0,8oC.
Assessment: fluid loss was assessed by measuring body weight loss.
(loss of body weight minimum 1% of BW before exercise)

(Armstrong, 2012, dan Ganio, 2011, dan Benton, 2011)


2. Instrument
WAIS (Wechsler Adult Intelligence Scale) Digit span Backward, an
auditory recall
Subject was given verbal serial number by the examiner. Participants
attempted to verbally recall the sequence immediately following its
completion in reverse order, with the speed of 1 number per second.
The serial number started from 2 digits to 6 digits. no grouping tone
and right arranged number is allowed (such as 4-5)
normal value= ≥ 3 digits
Statistical analysis

• Chi-square test (significant if p<0,05)


• SPSS versi 20,0 multilingual was used for this statistical analysis
Experimental flow Population

Inclusion criteria Exclusion criteria

Sample subjects

Short term memory function assessment in euhydration state (pre test)


using WAIS (Wechsler Adult Intelligence Scale) Digit span

Intervention group (31 subjects) Control group (31 subjects)

Treadmill induced dehydration (40 mn) + pre and post BW measure

Rest without eat and drink (20 mn)

Short term memory function assessment (post test) using WAIS (Wechsler
Adult Intelligence Scale) Digit span
Results
WEIGHT LOST PRECENTAGE BASED ON AGE IN
INTERVENTION GROUP

% Weight loss
Age (Year) Total
1-1,5% 1,5-2% 2,5-3% >3%
subject
20 6 4 2 1 13
21 9 2 2 - 13
22 1 2 - 1 4
23 1 - - - 1
Total
17 8 4 2 31
Subject
1% weightloss is equivalent with 1% body fluid loss in intervention subjects

100% of subjects in intervention group experienced acute mild dehydration,


assessed by >1% BW loss
I. WAIS DIGITSPAN BACKWARD TEST SCORE ON INTERVENTION GROUP
(DEHYDRATION)
Pre-test Score Post-test Score
Age
2 3 4 5 6 7 Mean 2 3 4 5 6 7 Mean
(Year)
20 3 3 4 3 - - 3,54 6 - 6 1 - - 3,15*
21 2 2 8 - 1 - 3,69 3 6 3 1 - - 3,15*
22 1 2 - 1 - - 3,25 2 - 1 1 - - 3,25
23 1 - - - - - 2 1 - - - - - 2
Total
7 7 12 4 1 0 12 6 10 3 0 0
subject
Symbol* on posttest refers to degraded score indicated STM function Impairment.

Mean score of age 20 and 21 show degrade, while age 22 and 23 remain stagnant.

Mean score pretest= 3.55


Mean score post test=3.06
I. WAIS DIGITSPAN BACKWARD TEST SCORE ON CONTROL GROUP
(NON-DEHYDRATION)
Pre-test Score Post-test Score
Age
2 3 4 5 6 7 Mean 2 3 4 5 6 7 Mean
(Year)
20 2 5 5 1 1 1 3,80 1 4 6 2 1 1 4,06**
21 - 5 4 - 1 - 3,70 - 4 3 2 1 - 4**
22 1 1 3 1 - - 3,66 1 - 2 2 1 - 4,33**
23 - - - - - - - - - - - - - -
Total
3 11 12 2 2 1 2 8 11 6 3 1
subject
Symbol ** on posttest refers to increased score indicated there was no indication of STM function Impairment.

Mean score of all age group increased.

Pre test mean score= 3.81


Post test mean score= 4.10
I. QUANTITATIVE DESCRIPTION OF DEGRADED AND NOT DEGREADED SCORE IN
INTERVENTION AND CONTROL GROUP.

Not degraded (%) degraded (%)

Control Group/Non-dehydration 28 (90.32) 3 (9.68)

Intervention Group/Dehydration 16 (51.61) 15 (48.39)

Total 22 (71) 18 (29)


Dehydration subject experienced impaired STM function more than non-dehydration subjects
(48.39% of 31 dehysration subj and 9.68% of 31 non dehydration subj)

STATISTICAL ANALYSIS WITH CHI-SQUARE.


Asymp. Sig
(2-sided)
Pearson Chi-Square 0,001
Significance value less than 0,05 showed significance rellation between variable
Discussion
intervention group (loss 1% of body fluid)
experienced degraded WAIS digitspan backward
memory function test.

Ganio, et al (2011)26 male 20 years old, significantly


impaired cognitive function, STM, and increase anxiety
(Computer Based Test) , increased plasma osmolality
(Urine Specific Gravity)
Armstrong (2012)  25 female 26 years old, not
significantly impaired in cognitive function, significant
difference in Profile of Mood States (POMS) and plasma
osmolality
Biller (2015)15 subjects, 25-29 years old, dehydration
induced anorexia

Increased plasma lower Na+ and Lower glucose lower H2O


osmolality by K+ level level by 8,7 ± level in brain
0,67% 6,8 mg/dl tissue by
1,63%
Cell shrinking

Decrease brain volume


Whole brain 0,36 ± 0,68%
Cerebral cortex 0,19 ±1,28%
White matter 0,59 ± 0.86%
Hipothalamus/thalamus 0,30 ± 1,80%
Streitburger (2012)6 subjects, 21-27 years old,
dehydration diet for 3 days

Average loss of body fluid 2,3%

Brain volume changes in ventricle system structure

CSF production decrease, significantly in 4th ventricle(p<0,001)


Trangmar (2015)10 male athletes, 24-34 years old,
dehydration induced with 2 hours ergocycle

Loss of BW by 3,2±0,3%

Blood volume changes in brain


Lower blood flow velocity in carotid artery
Lower blood flow velocity in middle cerebral artery
Control group  show increased score WAIS digitspan backward.
Subjects understood the test mechanism better in post test, thus,
they got better results.
In intervention group, there are subjects who didn’t
experienced STM impairment eventhough they have
lost minimum 1% of Body fluid (51.61%),
In control group, there are subjects who experienced
STM impairment eventhough they didn’t lost any
body fluid. (9,67%).

Another Confounding factors affect Short term memory function


Another factors effect STM function, which researcher
unable to control

-Gen expression (CREP-C/EBP -Sleep quality (REM/NREM) (Lau,


pathway) (Stern, 2014) et all. 2015)
-Air polutions (Gatto, 2014) -Music training (Suarez, 2016)
-Neuromodulator (dopamine, -Extensive Cognitive learning
adrenalin, stress hormon (learning to juggle, mirror
corticosteroid, insulin growth reading, new color names, motor
factor II) (Stern, 2014) exercise, video game, mediation)
-Light exposure(Shan, et all. 2015) (Koch, 2015)
Conclusion
In conclusion, this study demonstrates that, in third year male medical
students, mild dehydration of ≥ 1% body mass loss induced result in
adverse change in STM function assessed by WAIS digit span backward
Limitation
• Small sample size, limited procedure/tools for other confounding
factors selection.

Recommendation
• Future studies should consider to control more confounding factors,
determine the effect of chronic dehydration on cognitive function
• To assess the effects of dehydration in cognitive function in risk
population such as elderly, diabetes patient, or stroke.
References
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Appendix
Chi-square test results
Chi-Square Tests

As ymp. Sig. Exact Sig. Exact Sig.


Value df (2-sided) (2-sided) (1-sided)
Pearson Chi-Square 11.273 b 1 .001
Continuity Correctiona 9.472 1 .002
Likelihood Ratio 12.048 1 .001
Fis her's Exact Test .002 .001
Linear-by-Linear
11.091 1 .001
As sociation
N of Valid Cases 62
a. Computed only for a 2x2 table
b. 0 cells (.0%) have expected count les s than 5. The minimum expected count is
9.00.
Ethical clearance
Trial 2
7–4
3–1–8
5–2–4–1 WAIS Digit Span
Pretest
8–1–6–3–7
3–8–1–7–5–4
Backward test
6–7–4–3–1–5–2
Subject is able to recall until................digit

Trial 2
7–4
3–1–8
5–2–4–1
Post Test
8–1–6–3–7
3–8–1–7–5–4
6–7–4–3–1–5–2
Subject is able to recall until................digit
Documentation of Digit
span test in control
group at Campus II
Muhammadiyah Malang
University
Documentation of
Dehydration induced in
intervention group at
Brawijaya Sport Center
Documentation of
Digit span test in
intervention group
at Brawijaya Sport
Center
Thank you