MC and the ER

psg712

Here we go again. I visited mom this morning and was there when her palliative care nurse came to make a monthly assessment. The nurse noted that mom was pretty drowsy. This was early in the day, which is normally her most alert and interactive time of day.

I told the nurse that I have noticed this extra sleepiness ever since mom started on a small dose of antidepressant a couple of months ago. This med was prescribed for "inappropriate" behavior - a seeming fascination with her private areas after recovering from a yeast infection. The behavior stopped soon after starting the med but she is zonked on it. My sister visited from out of town a few weeks ago and found her at the breakfast table with her face in her plate.

My plan today was to contact the prescribing NP and ask her to stop the antidepressant. Before I had opportunity to do this, the NP called me at work and said that the 3rd shift staff had wanted to send her to the ER last night because she was extremely fatigued and weak. Thankfully they talked with the nurse/health director, who knows how I feel about that and said no.

Then ensued the usual fruitless discussion about how they are trying to get a urine specimen but mom just won't cooperate. The last couple times they got a specimen positive for infection, they sent her to the ER where catheterized specimens came back squeaky clean. MC put her on antibiotics several times in succession...thus, the big yeast infection which caused major agitation and behavior changes.

Today I got the NP to agree to "wean" her off the antidepressant (she's on the lowest dose) by breaking it in half for a week and then stopping. I also texted the health director and made it clear that I don't want her sent to the ER if she gets antsy with this change - give her time to adjust. This whole scenario is ridiculous. She is stable in terms of weight, appetite, level of cognition except she is overmedicated right now. She may not be hospice appropriate yet but I have a really low threshold for requesting that evaluation. One more useless ER visit would trigger it for me.

Thanks for listening! Ideas are welcome.

H1235

When is she taking the antidepressant? At one point they had mom taking hers in the morning and she was tired all day long. Switching it to the evening made a big difference. I have no experience with hospice. What is your reason for holding off on hospice (I’m trying to learn what I can before it’s needed)?

sandwichone123

My dh went on hospice recently and for me the biggest benefit has been that I don't have to stress that they'll send him to the ER at the drop of a hat.

psg712

https://alzconnected.org/discussion/comment/271043#Comment_271043

Mom is taking her antidepressant in the evenings but is zoned out all day.

I have mentioned hospice to the health director in the past, usually after an ER visit or hospital admission. She has discouraged it, saying mom "isn't at that point yet." I'm guessing this is because other residents who receive hospice services at the MC are wheelchair bound, require hand feeding, etc and my mom is not yet in that situation.

It's a little bit like when mom was still in AL and had stopped bathing or dressing herself, sat in her room all day doing nothing, stopped feeding her beloved cat, couldn't find the dining room at mealtime...and they said she wasn't priority for a move to MC because she wasn't exit-seeking or aggressive toward others. I had to push for the move.

caregiving daughter

Can you involve a psychiatrist or geriatric physician in your mom's case? I found the medications super powerful and really felt an expert should be involved vs. np.

psg712

https://alzconnected.org/discussion/comment/271114#Comment_271114

I agree that psychoactive meds should be supervised by an expert. I reluctantly agreed to the low dose antidepressant in the first place only because the facility leaders were so flipped out by her behavior, which I believe was really generated by the yeast infection. She has never done well with any mind altering meds, so I'm eager to get her off this one.

For her to see a psychiatrist would be a months long wait and a trip out of the facility, which is getting much more difficult for her lately. Unfortunately the NP is the most immediate provider. But she made a comment about the medication in our conversation that showed me she doesn't understand well how it works. To your point ...she shouldn't be prescribing this type of drug!

Anonymousjpl123

@psg712 I’m sorry it’s so hard. My mom’s meds took a while to stabilize. I think this phase - where your mom’s disease is progressing but she’s not completely gone - is just really hard to manage and predict. I am so glad you are able To be. clear with the doctors about what you want for her: you know your mom best. I completely agree re:unnecessary ER visits.

All this said, I hate to say this, hospice has really helped my mom. She had a terrible fall last summer that brought her to er (superficial but she fell and cut her head) and shortly after went on hospice. IT came with a lot of extras - extra set of eyes, extra supplies, extra medical care team keeping track of her. Once when she was in pain after a minor fall they gave her morphine which freaked me out, but other than that, zero regrets. 9 months later she’s stable where she was, though they say she still qualifies. It may be worth looking into.

caregiving daughter

https://alzconnected.org/discussion/comment/271142#Comment_271142

I understand your comments. I'm sure every facility is different as I we did have a psychiatrist that was able to visit the building, upon request from the floor nurse. It's a hard balance to ask questions of the clinical team but also try not to be viewed as a complainer. I know you are doing your best.

psg712

Thanks everyone for the ideas and support! Yes, it's difficult at times to tell if her drowsiness is due more to meds or to progression of dementia. The timing of onset of this just seemed to track with starting the new meds.

psg712

Update: Mom is off the antidepressant now. I've been checking on her about every other day in the mornings on my way to work. Over the past week, on all but one day she was much more alert and interactive. Pretty much back to baseline.