Anyone in a similar situation? Parent w/ anxiety, depression, benzo & alcohol addiction, MCI

caringformom0507

My mom (69) lives with my sister & sister's husband. Her mental health issues have been escalating over the years, rising sharply after she was laid off and pandemic hit. When short term memory issues became very evident, we started attending all her medical appointments and pushing for neuro assessments.

Here's what we know:
- Long-term severe anxiety & treatment-resistant depression (tried countless pills and even medical ketamine)
- Addiction to lorazepam (taking as prescribed DAILY for 6+ years), has been tapering down her dose very slowly just this year
- Prescribed Ritalin daily (not sure what genius psych got her on this cocktail but her current psych is keeping her on it)
- Addiction to alcohol that has escalated slowly for ~2 years, taken WITH the lorazepam. She hides alcohol and is unable to stop drinking even though she has tried. Don't know exactly how much she drinks but likely ~4 oz/vodka day or possibly more. She admits this is self medicating so she can "sleep" & "escape". However, she is not suicidal.
- NO dementia diagnosis but MRI shows "cognitive impairment" affecting short term memory & executive functioning
- Neurospych exam put her at the very bottom (less than 1%) for short term memory
- Docs don't recommend pursuing Alz diagnosis but say to get off all the pills and alcohol first (easier said than done). Her B1 is normal so it doesn't look like Korsakoff.
- Her therapist says she needs a "higher level of care", we are looking to get her into an in-person PHP substance abuse program but can't get her in for about a month.
- We're looking at in-person rehabs but I'm weary because we're not sure if she's "ready" and the complexity of her case worries me--can they handle it?
- She says she's "close" to hitting rock bottom, wanting treatment, that she doesn't want to live like this, but I'm not sure I believe she is ready.
- She cannot handle her own medication. My sister is dispensing all of her meds and it is a point of conflict.
- She recently agreed to take a Breathalyzer before driving, but we think we need to stop her from driving altogether.

I know that's a lot. We feel like we're drowning. We're angry and frustrated that it got to this point.

I don't feel like we fit well into one category of support group: She doesn't have Alzheimers or official dementia diagnosis, her alcoholism is so recent & intertwined with her other issues that it seems hard to relate to al-anon groups, and her benzo problem (which I believe is at the root of her decline) is not an "illicit" drug problem--she is taking this poison "as prescribed" so we also don't fit in at nar-anon.

Reading posts in this group about Korsakoff and alcohol struggles struck a chord with me and I'd love to find anyone who can relate to what we're going through, or if there are any support groups that might be appropriate. I know it will never be a 100% match but I'd love any suggestions. Thank you so much.

housefinch

Wow, that sounds like a lot to handle. I’m sending you hugs and support. Excuse this rambling response as I’m writing as I’m thinking.

She should probably see a board certified addiction psychiatrist (maybe that’s who saw her).

Don’t let her drive under any circumstances. She could harm herself or others.

Unfortunately many people prescribed benzodiazepines for anxiety can develop addiction because of underlying mental health symptoms they are self treating. I’m saying this completely without judgment. This can include past trauma, depression, anxiety, undetected ADHD or executive functioning deficits and the anxiety they cause, etc. Many people lack access to mental health care or can’t leave work to attend appointments. So a medication prescribed by a PCP that helps them cope gradually becomes an addiction. I am incredibly sorry for your mom that things have progressed to this point. It’s difficult to know anything about possible dementia or other disorders until she is completely off substances, because the substances and benzodiazepines will influence her neuropsychological test results.

The only other suggestion I have is whether you have an academic medical center anywhere near you (Eg medical school affiliated with hospital). If there’s a department of psychiatry, they might have an addiction psychiatry program she could enter. Those programs might have a patient navigator who could help guide your mom & family through the many steps you have ahead. They also might have a social worker with knowledge of support services, funding, etc. It sounds like this is going to be a long marathon for everyone.

Hopefully others here will have good advice for you.

housefinch

I would be absolutely sure her physicians feel that medically she’s ok for outpatient treatment (meaning, she won’t have alcohol withdrawal needing inpatient treatment when she stops drinking). I’m sure she’s seeing people who know what they’re doing. I’m just paranoid (I’m an MD & was taught to always double check everyone else’s assessment of a patient). I am absolutely no expert!!! I just think if she cannot stop drinking & is hiding alcohol, I hope she will actually detox completely if not in a totally controlled situation like inpatient. I guess those are things I would ask.

housefinch

@harshedbuzz might have good ideas

harshedbuzz

@housefinch

Thanks for the bat signal.

@caringformom0507

Hi and welcome. I am sorry for what your family is going through but so glad you reached out. My father was my PWD. He had mixed dementia including WKS as a result of alcohol use disorder. He didn't abuse alcohol until fairly late in life as a means to self-medicate after my younger sister died. I believe he was living with mental health issues; his geriatric psychiatrist thought it might be bipolar disorder, but I have a friend who is a clinical psychologist who felt he had more psychopathic tendencies that he was better able to control before he lost the social filter early in his dementia.

You said:

"I don't feel like we fit well into one category of support group: She doesn't have Alzheimers or official dementia diagnosis, her alcoholism is so recent & intertwined with her other issues that it seems hard to relate to al-anon groups, and her benzo problem (which I believe is at the root of her decline) is not an "illicit" drug problem--she is taking this poison "as prescribed" so we also don't fit in at nar-anon."

I get this. The intersection of mental health issues and dementia is not a very clear-cut. No one support group is going to fit this situation exactly, but I think you could get support/understanding to take away from all of those groups even though their spin on things may be contradictory at times.

Have you gone to meetings? I know these can vary a great deal in terms of the focus of those at the meeting. There are groups that welcome those who are taking prescribed meds that have become a problem for them. The fact that mom is prescribed her benzos doesn't make it any less of an addiction. Many people come to addiction via a well-meaning physician's prescription tablet. And washing benzos down with vodka is certainly not "taking as prescribed". The bigger piece is whether mom feels this is a problem for her. Because if she doesn't than policing her actions is the only way to limit her behavior.

- Long-term severe anxiety & treatment-resistant depression (tried countless pills and even medical ketamine)

That's unfortunate. If she is cognitively impaired, she may not be able to access other approaches to the management of her depression/anxiety.

- Addiction to lorazepam (taking as prescribed DAILY for 6+ years), has been tapering down her dose very slowly just this year

- Prescribed Ritalin daily (not sure what genius psych got her on this cocktail but her current psych is keeping her on it)

Some doctors prescribe low dose Ritalin for folks in the early stages of cognitive impairment as a way to bolster their focus, memory and executive functioning.

- Addiction to alcohol that has escalated slowly for ~2 years, taken WITH the lorazepam. She hides alcohol and is unable to stop drinking even though she has tried. Don't know exactly how much she drinks but likely ~4 oz/vodka day or possibly more. She admits this is self medicating so she can "sleep" & "escape". However, she is not suicidal.

4 oz of vodka is about 2-3 standard drinks. That is more than recommended for a woman without a benzo on-board, but probably not enough to trigger WKS. Certainly not in a short 2 years. Of course, it is possible she drinks more or has been drinking longer than you realize.

- NO dementia diagnosis but MRI shows "cognitive impairment" affecting short term memory & executive functioning

I'm a little confused by this. Imaging is usually ordered to rule out other causes of dementia/impaired cognition. An MRI might show a tumor or areas damaged by previous strokes. They might show some shrinkage of the brain that is greater than expected for her age. Normally testing-- like a neuropsych test or even things like MMSE or SLUMS are used to demonstrate specific cognitive losses like memory or spatial reasoning.

- Neurospych exam put her at the very bottom (less than 1%) for short term memory

- Docs don't recommend pursuing Alz diagnosis but say to get off all the pills and alcohol first (easier said than done). Her B1 is normal so it doesn't look like Korsakoff.

The 1% for short-term memory is very worrisome in the context of driving. It is what you would expect to see in a person with WKS-- the short term and working memory are damaged very early on. This make learning nearly impossible which complicates the use of non-pharmacological approaches to mental health and sobriety to supplement medication. Things like CBT, DBT, and or a 12 Step Program are less likely to work.

Dad's Thiamine levels were "low-normal" when he began IV supplementation in the hospital. That and maintaining abstinence seemed to improve his memory and executive function until he got out of SNF/rehab and could access alcohol again.

- Her therapist says she needs a "higher level of care", we are looking to get her into an in-person PHP substance abuse program but can't get her in for about a month.

- We're looking at in-person rehabs but I'm weary because we're not sure if she's "ready" and the complexity of her case worries me--can they handle it?

This is where things get complicated. We looked into alcohol rehab for my dad when he was in the early middle stages. You may have an easier time given that your mom isn't 70 yet (a surprising number of places use 70 as a cut-off point for psychiatric services), but we found exactly -one- rehab that would even consider taking dad on; I'm in the Philadelphia are which is quite well-served in terms of behavioral health. The director was very frank that he didn't expect that dad would be able to tackle the work of sobriety with his short-term memory and executive function deficits. He'd have learn new ways of thinking and then recognize when he needed to pull those new strategies out and apply them.

- She says she's "close" to hitting rock bottom, wanting treatment, that she doesn't want to live like this, but I'm not sure I believe she is ready.

She may be, but it could be she can no longer do the work she'll need to do to get there. Has her current psychiatrist tried any medications to dull her cravings for alcohol? We accidently landed on Wellbutrin as effective at dulling dad's cravings for alcohol. It was an off-label application, but it is used to help people with smoking and disordered eating. I read that Ozempic can also work in the way for some people.

- She cannot handle her own medication. My sister is dispensing all of her meds and it is a point of conflict.

Ugh. This is hard. You could keep mom sober by stepping in as the medication and alcohol police and endure all the ugliness that will bring. It's hard.

- She recently agreed to take a Breathalyzer before driving, but we think we need to stop her from driving altogether.

I wouldn't trust her with this. If her short term memory is in the 1st percentile, she shouldn't be driving even if she is sober.

Reading posts in this group about Korsakoff and alcohol struggles struck a chord with me and I'd love to find anyone who can relate to what we're going through, or if there are any support groups that might be appropriate. I know it will never be a 100% match but I'd love any suggestions. Thank you so much.

I'm curious, what part of the Korsakoff's postings resonated with you? My dad was diagnosed with it as the result of alcohol use, but I also suspect that my late sister had this as well in the last 9-12 months of her life as well. She died from complications of AIDS in the early 1990s and WKS was the dementia that end-stage AIDS patients sometimes had. It was interesting how different and yet the same their symptoms were- the cold, the crazy confabulations, the paranoia and anger were the same.

HB

caringformom0507

Thank you @housefinch and @harshedbuzz for the speedy and thoughtful replies.

@harshedbuzz -- Thank you for sharing your father's story. I'd like to address some of your questions.

Have you gone to meetings?

I've just been researching al-anon but have not tried a meeting yet. Right now I am juggling individual therapy, family therapy w/ my sister, and just recently communicating w/ my mom's therapist including family sessions there. So I'm resistant to adding another thing to my plate, on top of researching & managing mom's care, but am open to trying. The thought of trying to find the right group is overwhelming. Do you have any virtual al-anon groups to recommend? Just thought I'd ask.

Some doctors prescribe low dose Ritalin for folks in the early stages of cognitive impairment as a way to bolster their focus, memory and executive functioning.

The Ritalin was prescribed because she complained of having low energy due to depression, not because of dementia. But this is helpful to know. Her current psychiatrist was horrified that she was prescribed this with daily benzos but has been keeping her on both in the hopes of finding the right anti-depressant in the meantime. Once I became involved in her care we started a taper plan for the benzos but it is "one thing at a time" and a slow road.

I'm a little confused by this. Imaging is usually ordered to rule out other causes of dementia/impaired cognition. An MRI might show a tumor or areas damaged by previous strokes. They might show some shrinkage of the brain that is greater than expected for her age. Normally testing-- like a neuropsych test or even things like MMSE or SLUMS are used to demonstrate specific cognitive losses like memory or spatial reasoning.

Sorry I conflated two things here. Her MRI showed brain shrinkage that the neurologist says is correlated with her memory loss and cognitive challenges. The neuro-pysch exams is what confirmed her low levels of short term memory & exec functioning. No signs of stroke or anything to determine cause, but doc says alcohol may be a factor more than the benzos.

The 1% for short-term memory is very worrisome in the context of driving. It is what you would expect to see in a person with WKS-- the short term and working memory are damaged very early on. This make learning nearly impossible which complicates the use of non-pharmacological approaches to mental health and sobriety to supplement medication. Things like CBT, DBT, and or a 12 Step Program are less likely to work.

Dad's Thiamine levels were "low-normal" when he began IV supplementation in the hospital. That and maintaining abstinence seemed to improve his memory and executive function until he got out of SNF/rehab and could access alcohol again.

Thank you for sharing this. Everything is moving so fast that we just implemented the Breathalyzer rule this week but all signs are pointing to a need to stop driving altogether. We are at a loss of how to approach this...it is the #2 issue beyond assessing if we can get her into rehab SOON. I am willing to go the legal route to take away her license if she does not give up driving voluntarily, but it makes me nervous how permanent that is when she is so "young" and that she MIGHT recover functioning when clean.

I will bring up WKS with her docs from now on, despite her normal B1. She was low on B6 but I believe that's unrelated to WKS.

This is where things get complicated. We looked into alcohol rehab for my dad when he was in the early middle stages...

This is very helpful information. We found two (expensive, out of state) rehabs that had special senior programs, but in state there are much fewer options but all claim to have experience with seniors. No one has mentioned an age limit.

 ...he didn't expect that dad would be able to tackle the work of sobriety with his short-term memory and executive function deficits. He'd have learn new ways of thinking and then recognize when he needed to pull those new strategies out and apply them.

I'd like to know more about this, if you have any resources to share. Was anything they tried with him effective? Is an expensive rehab program "worth it" if this is the case?

as her current psychiatrist tried any medications to dull her cravings for alcohol?

Her psychiatrist has not tried anything explicitly for alcohol cravings, but I don't think she understands the extent of my mom's problem, as I've been trying to convey to her for several months now... my mom's "cravings" seem to be tied to her need to "escape" and "sleep NOW" more than to the alcohol itself. But I will bring this up with her doc.

You could keep mom sober by stepping in as the medication and alcohol police and endure all the ugliness that will bring. It's hard.

For awhile, we were the alcohol police and providing her with low, measured doses each day with her doctor's knowledge. But then she started sneaking around and she will not give up her private stash. Yeah, my sister could search her room and snatch it, but she would just get another. Being the med police is much easier, and I will be vocal in telling her doc to speed up her benzo taper since she cannot control her drinking. Unfortunately we can't speak with doc until June 1.

I'm curious, what part of the Korsakoff's postings resonated with you? 

https://alzconnected.org/discussion/comment/112335#Comment_112335 --> This thread really hit, and I see you have posted extensively in it :-) It is the people speaking of feeling alone and stigmatized because of the alcohol issue, of having a good parental relationship until this happened, and also sparking fears for me of things that have not happened yet, like DUI, car accident, severe falls...

It seems to me that the one true path to keeping my mom safe is to get medical & financial POA against her* wishes and force her into a residential care that she would pay for out of pocket. She can afford it in the short term, but I worry treatment now will be ineffective if she isn't ready and will permanently harm our relationship with her. This is all happening so fast, and every day it's something new. Really struggling to keep up.

*I will add that NO ONE, including any of her docs or therapist, have suggested this. But I'm not sure they even would.

harshedbuzz

This is going to be a little fractured and disjointed. Sorry.

@caringformom0507 said

"I've just been researching al-anon but have not tried a meeting yet. Right now I am juggling individual therapy, family therapy w/ my sister, and just recently communicating w/ my mom's therapist including family sessions there. So I'm resistant to adding another thing to my plate, on top of researching & managing mom's care, but am open to trying. The thought of trying to find the right group is overwhelming. Do you have any virtual al-anon groups to recommend? Just thought I'd ask."

Good for you to be putting on your own oxygen mask first and also working with your sister.

Do you feel as though your mom is getting anything out of her therapy once she leaves the session? I ask because given her abysmal short-term memory, one has to wonder what she takes away from therapy in terms of learning coping strategies or implementing new ways to frame things.

I don't know of any virtual groups, but I do know those in trouble with prescription medications are welcome. LOL, when I had my knee replaced a few years back, my late sister's ex-husband's soon-to-be 3rd ex-wife urged me to attend an NA meeting as a kind of guard rail. She's in recovery and works as a counselor in the field now and was terrified I'd become addicted to the pain meds I was using.

"Her current psychiatrist was horrified that she was prescribed this with daily benzos but has been keeping her on both in the hopes of finding the right anti-depressant in the meantime. Once I became involved in her care we started a taper plan for the benzos but it is "one thing at a time" and a slow road."

Sometimes a psychiatrist will start a low dose SSRI or antipsychotic while on a benzo and then start to taper the benzo once the other med has started to kick in at around 4-6 weeks. I wonder if the Ritalin is contributing to the sleep issues? Is she taking the extended release or the shorter acting OG version that would wear off in 4 hours?

"This is very helpful information. We found two (expensive, out of state) rehabs that had special senior programs, but in state there are much fewer options but all claim to have experience with seniors. No one has mentioned an age limit.

I'd like to know more about this, if you have any resources to share. Was anything they tried with him effective? Is an expensive rehab program "worth it" if this is the case?"

Ultimately, we decided against the program. Dad wasn't bought in and wouldn't have participated. He was one of those folks who never took ownership of fault or poor choice, so we skipped it. The director said this program was designed for seniors with memory issues and addiction. He said the used an "error-free" learning approach.

"It seems to me that the one true path to keeping my mom safe is to get medical & financial POA against her* wishes and force her into a residential care that she would pay for out of pocket. She can afford it in the short term, but I worry treatment now will be ineffective if she isn't ready and will permanently harm our relationship with her. This is all happening so fast, and every day it's something new. Really struggling to keep up.

*I will add that NO ONE, including any of her docs or therapist, have suggested this. But I'm not sure they even would."

I'm not surprised that no medical professional has suggested obtaining conservatorship/guardianship-- that's legal advice and outside their lane. The other piece is that as their patient, they have an obligation to her not you. If she's able to showtime they probably don't get a sense of what the day to day is like.

It is likely she will be very angry if you and/or sister obtain guardianship. How long she is able to maintain that ire is anyone's guess. My dad, who was a tough customer, eventually settled down. I was OK with his anger, but I'd worked through our lousy relationship which meant I was able to let it roll off my back more easily than most.

When I had the chance to send dad to rehab, I didn't think it would be worth the investment and that that money would be better spent for his care down the line.

HB

caringformom0507

@harshedbuzz Thank you again for the thoughtful replies. You've given me a lot to think about.

Would you be willing to share the name of the treatment center that had the program for seniors with memory and addiction issues?

We are in IL, but the two out-of-state centers we have looked at are Caron in PA and Hanley Center in FL.

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harshedbuzz

@caringformom0507 said:

"Would you be willing to share the name of the treatment center that had the program for seniors with memory and addiction issues?"

I don't recall the exact name. So many facilities changed names post-COVID's worst outcomes to avoid association with reports of deaths that it's hard to know whether a place was rebranded or changed ownership/mission.

This place is in the building formerly occupied by the one suggested to us by the social worker at Penn's Memory Center- Gaudenzia on Henry Avenue. Maybe it's the same people, maybe not. The do still include seniors/65+ as a program. FWIW, many drug and alcohol treatment facility refer to anyone 50+ as their elder population. Their website isn't working, but here's contact information.

Gaudenzia - Henry Avenue in Philadelphia, Pennsylvania • RehabNow.org

"We are in IL, but the two out-of-state centers we have looked at are Caron in PA and Hanley Center in FL."

My late sister's former husband and his soon-to-be 3rd ex-wife are both addiction professionals and in recovery themselves (almost 30 years for him and about 20 for her). They have sent his younger daughter to Caron more than once so I am guessing they think well of it. She generally did well there but has never been able to maintain sobriety on the outside for long. They are leery of Florida in general. During their Master's programs they did clinical work in FL as part of their education and came away feeling that some-- not all-- of the addiction industry in FL was more about money than helping folks achieve and maintain a sober lifestyle. I'd ask a lot of questions about what happens after the intensive part of the program.

I can't say whether Hanley is a good program or not. But this is what they have to say about their "senior program"--

___________________________________________________________________________________________________________________

In 1998, Hanley Center pioneered age-specific addiction treatment when it opened the Center for Older Adult Recovery. Today, our program offers senior and mid-life addiction treatment specifically for men and women aged 60 and older.

At any age and any stage of life, we promote a transition from substance use to enhanced wellness — body, mind, and spirit. Whether you have been battling addiction for many years or a recent life event has set off a cycle of substance use, we can provide the clinically excellent, individualized care you need to achieve lifelong recovery.

Misconceptions About Older Adult Addiction Are Prevalent

Roughly one-third of older adults with a substance use disorder suffer from late-onset addiction. Significant life changes, such as a sudden illness, the loss of a loved one, or problems in relationships, can send a person spiraling into unhealthy behaviors and substance abuse/misuse.

No matter what your age, the reality is that the difference between active addiction and treatment can be loss of life. At Hanley Center at Origins, we want you to feel that the rest of your life is always worth living. Each patient’s evolving plan of care integrates advanced medical, psychological, and psychiatric therapies provided by a highly credentialed, multidisciplinary team.

Detoxification and stabilization through acute medical care is the first step in overcoming addiction. During treatment at Hanley’s Center for Older Adult Recovery, our patients begin to regain health, boost cognition, improve mobility, and rebuild their relationships. Combined with participation in 12-Step practice, our patients receive a design for living that can restore freedom from active addiction.

Elements of Age-Specific Treatment

Building a supportive community is a vital part of recovery. Clinical studies and experience show that forming these essential bonds is easier among people who have similar life experiences and perceptions. This is why age-specific care is at the heart of Hanley Center’s treatment strategy. Our program is tailored to address the shared values and outlooks of every generation. We work as a coordinated team to provide compassionate care that accounts for your past, present, and future.

____________________________________________________________________________________________________________________

This all sounds good, but I don't know whether your mom has the cognition and self-awareness to do the work of recovery or maintain that state with her diminished short-term memory.

HB