Signs of dementia

"The Impact of Dementia on Your Family's Wealth"

                                                                                                                                          Please join us in San Mateo on Thursday, September 11th for an important talk about early dementia and financial challenges. How would dementia affect your family’s wealth? What happens if an elder starts giving money away to anyone who asks? What if they start gambling and can’t seem to stop? What are the risk factors in not planning financial safeguards? How does elder financial abuse happen- and how prevalent is it? These and many other questions will be discussed with Dr. Landsverk and Certified Financial Planner Ben Pettigrew in an interactive discussion.• 12:00-2:00 • Lunch provided by Les Koonce and Ben Pettigrew of LPL Financial -Contact Adrienne Galvez at (650) 321-6068 or Adrienne.galvez@lpl.com

Location: Franklin Templeton Investment Headquarters at One Franklin Parkway, San Mateo, Building 920, First Floor, H.L. Jamison Auditorium

 

 

 

 

 

 

 

Dementia Myth No. 3: “Just Give Him a Sleeping Pill. Or a Tranquilizer.”

Woman with pillsAlmost nothing in my practice drives me more nuts than the relaxed attitude both our society and our medical establishment have toward prescribing sleeping pills and tranquilizers to elders, especially to elders with dementia. As I travel around the San Francisco Bay Area doing house calls and treating people with complicated dementia cases, I often find that my new patients have been treated with sleeping pills or tranquilizers. Sleeping pills like Ambien or tranquilizers of the “benzodiazepine” class— Lorazepam/Ativan, Alprazolam/Xanax, Triazolam/Halcion, or Clonazepam/Klonopin, to name just a few, there are dozens of brand names—can often cause more troubles than they solve in elders with dementia. Yes, these drugs do give temporary relief, but the price is often long-term problems.

It’s very common for elders with dementia to have disturbed sleep patterns. Many of my patients would love to sleep all day and stay up all night. But giving a dementia patient a sleeping pill very often makes them much more confused. A much better strategy is to wake the patient during the day when they try to nap. Find activities the elder will enjoy, and then encourage these pleasurable things. Keep an elder’s interest and engagement up will keep them awake during the day and help them to sleep at night. In general, I find that sleeping pills often worsen the symptoms of dementia.

As I’ve described in recent posts, dementia patients often suffer from severe anxiety and delusions. There are times when it’s appropriate to use an anti-anxiety medication for a quick result. Let’s say you’re trying to make it possible for an elder to tolerate a medical procedure, then a tranquilizer might be in order. Or, let’s say an elder has suddenly gotten completely out of control at their residence. If they’re lashing out, screaming and hitting people, a tranquilizer may alleviate the emergency of the moment. But as soon as the chaos is calmed, I always try to get my patients off tranquilizers as soon as possible.

In dementia patients, I have found that prescribing tranquilizers long-term often makes a patient situation worse. Rather than alleviating anxiety or confusion, it often makes those problems more severe in dementia patients. Paradoxically, tranquilizers will make some patients more agitated, not less. I have even had patients who became psychotic on tranquilizers.

Not only this, but tranquilizers are famously addictive. It can be difficult to taper down these medicines once a dementia patient gets used to them. If you discontinue these drugs too quickly, they can cause delirium. Often, I encounter cases where the delirium is blamed on the dementia, but usually the tranquilizers are to blame.

If your elder is on sleeping pills or tranquilizers long-term, those drugs may be the problem, not the solution. Check out our medication section on the ElderConsult website. Then starting asking questions

Dementia Myth No. 1: You can predict the progress of dementia

No, I’m afraid that you can’t. As I stated in my previous post, we as a society cling to the idea that dementia is simply a gradual fading out, a progressive loss of memories and self-awareness. While that’s not exactly comforting, it’s less disturbing than many of the cases that I see every day:

Confused elders whose illness has made them so anxious that they live in a state of constant terror.

Elders whose disease has made them dangerously paranoid, unable to trust anyone, convinced that everyone is trying to hurt them or kill them.

Elders who hit and bite and kick anyone who comes close to them, making it next to impossible to care for them properly.

Elders whose dementia has erased all their inhibitions, making them hypersexual. These elders make inappropriate comments. They may grope passers-by. They may make advances on caregivers, family members, you name it.

Elders who run away, again and again. They slip out through doors. They climb out of windows. They scale fences. They may wander miles and miles, for hours, sometimes even days. Each moment that they are out on their own they are in danger: of being hit by a car, of being abused, of being robbed, of experiencing a health emergency because they aren’t taking their medications.

Elders whose dementia has changed their brains in such a way that they feel an overwhelming need to engage in repetitive behaviors: They may swing their arms. They may walk constantly. They may cry out endlessly, even though there’s nothing wrong. They may ask the same questions over and over and over, or make the same statements, driving everyone around them a bit crazy.

While sometimes these behaviors start gradually, it’s common for them to begin at the snap of a finger. I believe it’s likely that this results from the physiology of many kinds of dementia. Alzheimer’s seems to be related to the build up of “plaques” that interfere with the signals between neurons in the brain. But there’s also vascular dementia—which can result from many mini strokes in the brain. There’s alcoholic dementia, which results from the damage of drinking too much. There’s dementia that results from other conditions like Parkinson’s disease. Sometimes, one of these maladies will just take out an important bit of the brain tissue, and suddenly you’ve got a behavior problem.

It can happen overnight. I’ve had patients who were charming and kind one day, then nasty and mean the next. A patient might be calm, then suddenly become inconsolably terrified or anxious. A patient may have a fairly solid grasp on reality, then suddenly come to believe that a devoted caregiver is trying to steal everything in the house, or that the hospital has been taken over by Nazis, or aliens, or unseen monsters.

Why do I think this is so important to point out? Because I believe that we all need to recognize that dementia is a dynamic, ever changing, malady. As healthcare professionals, family members and caregivers, we need to constantly be alert to changes in a patient’s behavior. We need to be willing to adjust our approach to dementia patients accordingly. We need to think nimbly, changing both behavioral and medical strategies as needed.

Dementia care is not a “set it and forget it” enterprise. It’s a day-by-day challenge. We all need to remember that.

Elizabeth Landsverk, MD

Board Certified in Geriatrics, Internal and Palliative Care Medicines House calls throughout the San Francisco Bay Area

Hard to Swallow, Part 2

liz_bio_pic                                                                                                                                                                                                                                                                                                                    Recently, I came across this story from a family that inspired more thoughts about swallowing: An elderly woman suddenly started holding her breath. She gagged whenever she tried to eat, and she started spitting up saliva. Her daughter, a nurse, thought, “Oh my God, this is it.” The daughter rushed her mother to the emergency room. The doctors at the ER confirmed the daughter’s fears: Her mother’s dementia had progressed, they said. Her mother was losing the ability to swallow, a development that often marks the beginning of the end.

The daughter asked the physicians to do what’s called a “swallow evaluation,” in which a doctor would thread an “endoscope” down the patient’s throat to see what was going on. The ER docs refused to do this, and suggested that the daughter arrange for it through primary care.

The next day, her mother started holding her breath again and was really beginning to suffer, so the daughter took her back to the ER. At first, the doctors didn’t want to admit her mother, but they finally relented. Again, the doctors insisted that the daughter needed to accept that the dementia had progressed, that this “was it” and so on.

The daughter responded that she was willing to make the hard decisions when the time came. But she wanted to be sure that she’d exhausted all possibilities first. She pushed for the endoscopic examination of her mother’s throat. Finally, the doctors relented.

When they did the evaluation, they found that the patient’s throat had narrowed in two places. They stretched out those “rings” and the patient is back home and doing fine.

Like the swallow story I described in my previous post, I think that this story illustrates one of the central challenges of caring for elders with dementia:

How do you find the treatments and evaluations that will improve quality of life, while at the same time avoiding treatments and evaluations that can be done, but are unlikely to improve quality of life?

In my practice doing house calls for patients with dementia, I have often seen cases in which elder may have dementia, but still has a pretty good quality of life. Then that elder gets pneumonia from aspirating food, that is, from getting bits of food lodged in their airways. Let’s say this happens twice in four months. Too often, patients will be referred to hospice in a case like this. But I have found that it’s often enough to decrease sedating medications and to prescribe a full course of antibiotics.

That’s the balance we must try to maintain in caring for elders with dementia: Do enough; but not too much.

Less sedation and antibiotics may be the solution in the case that I just described. But let’s say the patient eventually progresses to a point where they really cannot swallow. In that case, I generally would not recommend a feeding tube. It might prolong life, but what sort of life?

Often, even at the end of life, there are all sorts of things that we still can do. The tricky question is: Should we? The answers are different for each family and for each case, but I think it’s always good to ask these questions: “Does the patient have a good quality of life? Will the exam or the treatment we’re considering add to that patient’s quality of life? If the treatment or the exam will not add to quality of life, then why are we considering it?

These are tough questions to ask and to answer. But I believe they are necessary questions.

Elizabeth Landsverk, MD - Specialist in dementia

 

Is Your Elder Neglecting Their Own Care?

A colleague recently forwarded me an essay from The New England Journal of Medicine about what we call in the field “elder self-neglect.”

The essay describes a patient who has piles and piles of paper in his home, rotting food in the kitchen, rat feces everywhere. It addresses what doctors and families might do in such a situation.

elder stress The authors of the journal essay suggest a few things:

1) Lowering our standards for safety and cleanliness, i.e. clearing paths through the clutter.

2) Making sure that the patient’s doctor works with the patient to identify goals and solutions.

3) Arranging for a home visit by the doctor, as one way of paving the way for a home care team.

4) Making “worst-case scenario” plans.

I’m glad that such a prestigious journal published this essay. As a society, we need to talk more about self-neglect. As the essay states, as many as one in ten older adults neglect their own care, and the rate is higher among poor and/or African American elders. We need to talk more about how we balance an elder’s right to make his or her own decisions against his or her safety.

The NEJM essay also makes these points, but then says that “many such people do not have moderate or severe dementia and so are not considered legally incompetent to make health care decisions.”

This is where I differ greatly from the authors. My feeling is that in rare cases, self-neglect may be a choice. Most of the time, as I do geriatric house calls around the San Francisco Bay Area, I find that self-neglect is a huge red flag.

A normally-functioning person simply does not want to live among rotting food, rat feces and piles of junk.

The first question to ask is, “Does this person have the mental capacity to make the choice to live this way?”

Caregivers, family and friends need to push for a full neuropsychological exam in a case like this. The “Mini Mental” exam, asking the person what day it is, or who the president is—that’s not enough to make an accurate judgment of their mental status. Plenty of elders I’ve met know what day it is, but also think they can talk to dead relatives or are happy to give out their bank account numbers to strangers.

Also, don’t forget that some medical conditions can create significant mental fallout: heart problems, cancer, Parkinson’s disease and many others. Ask your elder’s doctor to explore whether a medical problem could be behind the self-neglect.

If the person does have capacity, then all we can do is to set up a structure (caregiving agencies and so on) that can swoop in if and when the person eventually loses capacity. Families should consult an elder care attorney to know their options. They should try to talk to their elder and ask them what they would want done if they were in the hospital, or if they lost their capacity to make decisions. Sometimes, elders are more open to this kind of conversation when there’s a problem or a crisis.

But most of the time, I find that elder who’s severely neglecting his or her own care does have some kind of dementia or a medical problem.

The authors of the NEJM essay emphasize compromises and working with the patient. Of course, I’m all for that. But remember, it’s next to impossible to negotiate with someone who has dementia. If a person gets a proper psychiatric evaluation—and that’s a full neuropsychological exam—and then is found incompetent to make health decisions, then that person needs to be protected.

That doesn’t mean snatching a person from his or her home. I believe that elders’ wishes should always be honored if at all possible. If a person doesn’t want to take non-essential pills (like vitamins), or if a person wants to bathe just once a week, that’s fine. But it’s not OK for an elder to be living in a home filled with piles and piles of paper. That’s a fire hazard. Clearing paths through the mess is not enough. It’s not OK for an elder to be living surrounded by rat feces. That’s a health hazard.

Of course, all elders who are able should be able to make their own decisions. Just make sure that self-neglect really is a decision, and not the sign of a deeper problem.

Elizabeth Landsverk, MD Specialist in Geriatrics