How do you get a dementia patient to cooperate with an MRI?

Jim32

My mother needs to have an MRCP (an MRI on the gallbladder and the liver).

Unfortunately, because of my mother's vascular dementia, she could not sit still for an extended period of time, and she could not obey the commands of the technicians. She kept bending her knees and putting her arms onto her chest. So, the MRI had to be aborted.

So, how do you give an MRI to a dementia patient? Is there some special MRI machine that has restraints that can keep a dementia patient in the proper position?

M1

Jim you probably can't without general anesthesia, and that would also be very risky for her. Can I ask what they are looking for? If it's biliary tree tumors or blocked ducts, there might be alternative procedures by a gastroenterologist but those would also involve anesthesia. I think the most important question is what could they find that you would do anything about? And that all depends on how advanced her dementia is.....

loveskitties

Hi Jim,  you don't say but does she have two different doctors...one for dementia and another who is ordering the MRI?  If so, you need to get them to talk to each other.  

If the scan is absolutely necessary there may be an oral med which could help to calm her enough to get the job done.  However, it would need to be administered correctly for the timing of the scan, as I have read this scan can take about 40 minutes.

Hope that you get some good input from the docs.

Cynbar

My DH is late stage 6 dementia, and I can't even imagine him undergoing a MRI. He can't follow instructions, has no patience or sense of time. Plus, it's a scary, uncomfortable experience, even with the more open MRI machines. The thought of restraints is terrible, he would be terrified. I agree with the observation above ---- what are you going to do with any results the MRI gives you? Put her through surgery or other invasive treatments? Most late stage dementia patients are moving towards comfort care only. You may want to talk to her doctor about concentrating on symptom management instead of diagnostics.

harshedbuzz

Is there another way to obtain the information the doctor is seeking?

And what would you do with that information? One problem with testing is that it can lead to a cascade of other invasive tests and procedures that might not be appropriate for a person with a terminal diagnosis.

HB

Jim32

Hello. Thank you for your responses.

I see from these responses that I definitely should provide more information.

My mother is 81 years old.

Five years ago, before any dementia occurred, we were told that my mother had stones in her gallbladder and stones in her liver. Regarding the liver, my mother had stones in the Common Bile Duct (CBD), the Common Hepatic Duct (CHD), and the Intrahepatic Ducts 

(IHDs) (bile ducts within the liver). The stones in the CBD and the CHD had come from 

the gallbladder, but the stones in the IHDs were DIFFERENT from gallstones and had NOT 

come from the gallbladder. Furthermore, the IHDs were in bad shape. They were uneven and 

irregular. The stones inside the IHDs were there BECAUSE the IHDs were in bad shape. 

Ordinarily, the liver stones would be removed via a procedure called the ERCP, and the 

gallbladder would be removed laparoscopically. However, her GI doctor said that, due to 

the risk of complications, the ERCP would not be done, and the gallbladder would not be 

removed.

Instead, my mother would take a medication called ursodiol. That medication would keep 

the gallbladder stones and the liver stones at bay. If the gallbladder became inflamed 

or the pancreas became inflamed or the stones started threatening my mother's life, then 

perhaps the gallbladder would have to be removed and/or an ERCP would have to remove the liver stones.

So, for the last five years, my mother has been taking ursodiol, and her gallbladder and 

liver issues have been stable.

Three years ago, my mother began having hallucinations. She started seeing deceased 

family members in our home. First, my father. Then, her parents. Then, her sister. As 

these hallucinations went on over the years, I reported them to her primary doctor. But 

he dismissed them as anxiety or depression.

In March 2021, she had a mental episode and was hospitalized for an evaluation. A CT 

scan showed ischemia and microvascular irregularities. This CT scan and her hallucinations led doctors to conclude that she had probable vascular dementia.

In early April 2021, she went into a nursing home. That home was getting her ready to be 

discharged to an assisted-living facility with memory care. In early May, she was taken 

to a hospital because of pain. The hospital discovered that she had fallen down and had 

broken her hip, and she underwent hip-repair surgery with general anesthesia.

The hip was repaired successfully. Unfortunately, the general anesthesia seemed to worsen her dementia. She developed severe behavioral issues, and she became incontinent.

After she recovered from the hip surgery and her behavioral issues improved, she was 

released back to the nursing home in early June 2021. But she remained incontinent.

The nursing home continued to get her ready to be discharged to an assisted-living 

facility with memory care.

In mid-June 2021, my mother's liver blood tests were bad. An ultrasound showed just one 

small gallstone, which led a nurse practitioner at the nursing home to suspect that my 

mother was passing gallstones. The ultrasound also showed a non-acute fatty liver. A GI 

doctor (not the one from five years ago) suspected that the liver stones had become a 

threat and ordered an MRI. So, the doctor hoped that the MRI would show whether there 

are still stones in the liver and whether these stones are now a threat. If they are a threat, they will be removed via an ERCP.

The MRI can not be done under general anesthesia. At some point during the MRI, my 

mother will have to hold her breath for a few seconds.

An ultrasound will not detect any liver stones.

Physically, my mother is very high-functioning and very strong. Her nurses (and the scratches that she gave these nurses) can attest to that. It's the dementia that is the 

problem. I do not know what stage of dementia my mother is in, but, given her physical 

strength, she could live for a few more years.

My mother does not yet have a dementia doctor. She was supposed to see a dementia-

related neurologist in May, but her hip surgery forced the cancellation of that appointment. The next appointment for a dementia-related neurologist was in late August 2021. However, my mother does have an attending physician at the nursing home.

Well, I hope that the above information is helpful to the people of this forum, and I hope to hear of a way to inspect my mother's liver for stones.

Thank you.

Iris L.

A very short acting sedative might be useful.  I prescribed a small dose of choral hydrate for pediatric patients before certain procedures.  Discuss this with the doctors involved.  Be sure they consider interaction with the medications she is already on.

Your mom is not high functioning.

Iris L.

Jane Smith

Disclaimer:  not a medical professional, although there are some on the boards who may have better advice. 

I am so sorry to hear about your mother and the complicated situation. No easy answers, and a lot going on, to be sure.

I think that a frank discussion regarding a short acting sedative (such as Versed or similar, like what is used for certain types of tests, but of course taking other meds and health issues into account) might be a way to get her into the MRI machine. 

Or the doctors might be willing to go ahead and schedule the ERCP without the diagnostic tests, if you explain the situation and are very insistent. That might have insurance repercussions so I’d be careful about that aspect. 

If she is in pain, of course that is a situation that needs to be addressed. 

If the goal is to relieve pain, that is understandable. 

If the goal is to obtain information you need to make a decision, again, very understandable, although with consideration about if the information is going to change the decision you make. 

A very wise person on these boards directed me to a book called Hard Choices for Loving People, by Hank Dunn, when I faced a similar situation with my own mother.  

I would also suggest a publication called Understanding the Dementia Experience, by Jennifer Ghent-Fuller. PDF here:  http://www.dementiacarestrategies.com/12_pt_Understanding_the_Dementia_Experience.pdf

As I am sure you know, vascular dementia can progress in more of a downward step way rather than a gentle curve. Any medical issue, no matter how slight, can worsen the situation. The change in patients with dementia after anesthesia, surgery, and hospital stays is sadly well known to many of us here (and hospital-induced delirium is as actual diagnosis and not limited to those with dementia).  It can take a long time to return to baseline after these events, and sadly, many of our persons with dementia do not return to their pre-event baseline. 

If you are curious about stages of dementia, and I do not suggest this lightly, there are different scales that are used.  They range from “mild, moderate, severe” to “early, middle, late” to much more descriptive scales. 

I personally find the Fisher scale most helpful, but would caution you to be very wary of reading the stage 7 descriptions right now when you have so much going on.

Frustratingly, I cannot find the correct website, but this gives you an idea:  https://www.alzinfo.org/understand-alzheimers/clinical-stages-of-alzheimers/

I hope you are able to find a solution. Very best wishes and I am so sorry. 

Jim32

Jane Smith wrote:

I think that a frank discussion regarding a short acting sedative (such as Versed or similar, like what is used for certain types of tests, but of course taking other meds and health issues into account) might be a way to get her into the MRI machine. 

Or the doctors might be willing to go ahead and schedule the ERCP without the diagnostic tests, if you explain the situation and are very insistent. That might have insurance repercussions so I’d be careful about that aspect. 

If she is in pain, of course that is a situation that needs to be addressed.

If the goal is to obtain information you need to make a decision, again, very understandable, although with consideration about if the information is going to change the decision you make.

  

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Jim32's post starts here:

Actually, my mother's current GI doctor initially said that he wanted to do the ERCP. I knew that the ERCP had a huge risk of infection (from what the earlier GI doctor had said), and I expressed concern over this risk. So, the current GI doctor ordered an MRI.

Subsequently, I found out that the ERCP would involve some level of sedation, maybe even general anesthesia. Since general anesthesia will make my mother's dementia worse (as general anesthesia did with the hip operation), I do not want my mother to have the ERCP  unless the ERCP is absolutely necessary.

Also, my mother is not in pain.

Furthermore, she had liver-panel tests 4 days after the mid-June tests and 11 days after the mid-June tests, and her liver values have been improving. So, it's possible that this liver problem will simply go away without any ERCP.

As for Versed, that is a benzodiazepine. My mother is given a benzodiazepine called Ativan at the nursing home from time to time. The thing about the MRI is that I was told that, for the 4 hours before the MRI, my mother was not to have anything to eat or drink, not even water or medications. 

M1

Jim, if this were my mother I would leave well enough alone. Unless she is in intractable pain, I would not put her through any more procedures.

dayn2nite2

I agree with leaving it alone.  In this kind of situation, you really only want to do invasive testing/procedures if the issue is life-threatening.  Even in someone who is "high functioning."  On a 0-10 scale, what would you rate her quality of life at this time?  Probably not too high.