If YOU had to pick a med for your loved one...
This probably sounds like a weird question and yet it is exactly what the pharmacist asked of us! He called us and told us that the geriatrician gave us three categories of meds and let us kind of pick what we wanted to try!!
So the category was anti-anxiety meds, anti-convulsant meds, and anti-psychotic meds. We were kind of surprised that we weren't give more guidance than that! We decided to go with Zoloft and Gabapentin.
She's taken the Zoloft for only about 6 days! I know that isn't nearly long enough to make a difference, HOWEVER I do worry that we didn't pick the right med for her?
She has almost constant delusions. She is particularly concerned about strangers living in her house. She calls us regularly when my Dad is in another room to complain that there are two of him! I'm heartbroken to see her so miserable.
I want to give the Zoloft enough time to see if it will make a difference, BUT this is clearly beyond what I've regularly seen Zoloft used for!
Would love any advice you can provide!
(Should mention we also picked up a script for Gabapentin. We have yet to use it! Maybe on the hardest days we should introduce it?)
TIA!
Comments
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As an internist i am shocked that the provider did not give you more guidance and that he turfed that important discussion to the pharmacist- both are completely inappropriate and i would be looking for a new doctor right away. Complete BS in my opinion- making that decision is his/her job, not yours!!!! That said, from what you're describing she probably needs an atypical antipsychotic like Seroquel or Risperdal to have any effect on the delusions, Zoloft and gabapentin aren't likely to improve those. Assuming no contraindications I would have started Seroquel first. I'd forget about the gabapentin, relative and Lamictal are the anticonvulsants that are useful in some cases but usually reserved as second line drugs for difficult cases.
you always have the option of taking her to the emergency room and asking for psychiatric evaluation and admission. Hospitalization is not easy but she may get stabilized faster in an inpatient setting. I suspect that's your best bet given that this doc is not giving you appropriate help.
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I agree with M1. I’m a pharmacist. I don’t specialize in neurology but I would think Zoloft and Gabapentin would have no effect on the delusions. But I don’t know the specifics of your LO’s case.
I do know that we had a similar experience with our neurologist in that they explained the benefits and risks of a couple of classes of Alzheimer’s meds. And they asked if we wanted to start any now or wait. But it was an informed decision that we came to as we consulted with the neurologist.1 -
Caregiver here— I agree with the others. Pharmacists are great around knowing side effects, interactions and ways in which a medication can be given, but drug options should be in the hands of a specialist physician— ideally a geriatric psychiatrist if you can access one.
Hallucinations call for an atypical antipsychotic. We were Team Seroquel for dad. These do have the scary Black Box Warning but given at the lower doses used in dementia are very effective for improving quality of life for the PWD and those who care about them.
Dad was already on an SSRI (Prozac) when diagnosed and we did increase that initially, but it wasn't enough for the anxiety and agitation. Seroquel was what did tamp down dad's delusions and his hallucinations (auditory and visual); the former were upsetting for him, but he never seemed troubled by his hallucinations (often friends or relatives). Zoloft might bring some improvement, but it could take a month or more to get a sense of what you can expect from it.
Gabapentin seems like a Hail Mary in this situation. It can impair cognition further and cause dizziness which increases fall risk. I wouldn't bother with this one.
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Saw autocorrect error in my previous post- depakote (valproic acid) is the other anticonvulsant useful here. Zyprexa and Rexulti are two other antipsychotics used. Zyprexa tends to have more side effects, and Rexulti more expensive and no better than the older drugs. But seriously, id be either in the ER today or on the phone complaining quite loudly to this so called geriatrician's office.
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Gabapentin is for nerve pain- such as neuropathy. I was told it does have ‘some’ antidepressant value. I doubt it does anything for delusions, hallucinations etc as it doesn’t alter brain chemistry. It can make people drowsy and unstable on their feet. I wouldn’t use it unless she had nerve pain.
You need a different doctor. His office should have called you and discussed these medications directly with you. Choosing across categories of medications is a medical decision- not one the pharmacist can make or advise about.
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I take gabapentin for anxiety and it helps me
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First, I'm glad that this is viewed as not normal! It was shocking to be given the choice of drug! Regarding hospitalization, I'm curious as to what this actually looks like? My mom is highly suspicious of regular doctor visits and we're working HARD to try and get her to be ok with finishing her diagnosis (by getting an MRI and a neuropsych analysis) . I just can't imagine what it would look like to take her to the hospital? Do you have to trick her to get her in the car? Upon arrival at the hospital is she put in a straightjacket and locked up? Or are there dementia patients who are totally ok with these kinds of interventions and go willingly? It just seems hard for me to imagine any adult with any faculties left being ok with being taken to a hospital. At the same time, it has been recommended to me many times so maybe my mom is different that way?
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I am in shock and appalled that this happened. Had your mom seen this geriatrician previously? As difficult as it is to get your mom to go to an appointment, you really need to have her evaluated by someone else.
I know it won't work for all of her appointments, but how would she respond to a virtual appointment? That way she would "see" the physician on the screen and talk then the next visit she could do in person? It's just a thought.
eagle
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The usual reason for hospitalization is inability to care for her at home under the current circumstances, that she is combative and/or a danger to herself or others. I hope you hold power of attorney for her, it's going to be much easier if you do (if not, you need to get on this asap with a certified elder law attorney, or you may have to file for guardianship, which is a harder process).
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My Dad has power of attorney. So that's good. She is fairly healthy. Still independent-ish. She needs my Dad's help to take her meds every day but she dresses and feeds herself. The tricky thing has been that this week he had to tell her that he couldn't talk about her concern any longer that day (she's concerned about not driving, the trust, her bank account). He has discussed these issues with her up to 100 times a day. But he finally just told her he could not talk to her any more! She's been angry and afraid of him ever since.
I actually don't think she really recognizes him. Some of the links in these forums have been really helpful for me to recognize that her difficulties arise from the fact that he does in fact look like a stranger to her! So she's fearful. And when he's perfectly patient, then she's kind of tolerant? But he only has to have one somewhat sharp word, or not speak with her concerns right away, or give the wrong answer and she'll kind of lock herself in her room or threaten to walk to my house. I have spoken with her on the phone several times and I think it has helped her to feel better. She often calms down throughout the day. It has been hard for me because I have four kids at home and my husband has been out of town this week. (Last week of summer before school starts next week!)
The trickiest parts of her behavior are, that she is nervous about her current situation (driving, trust, bank account) and our answers never satisfy her because she can't remember the discussion and she isn't logical. And then on top of that, she doesn't recognize people in her home, which has led to imagining that they're strangers. So my sisters have taken turns staying in the house and she gets the impression that there are two of them (nice and mean versions) and she has the same impression about my Dad.
So the problems we're seeing are the fear and anxiety on her part largely. I just don't see how hospitalization will help her.
I've mentioned this in another thread but the healthcare that they have is Kaiser. This is a system in many parts of the US that means that you can see any of a number of "Kaiser" doctors. But oftentimes care is standardized. We might try and find a better geriatrician in the system (and we will try!) but we will probably have to jump through the same hoops!
To switch doctors outside of Kaiser coverage would mean that they'd pay for all costs OOP. Which would be a financial strain for them. I can ask my dad about options to go to other health coverage and when the open enrollment window is!
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I was told by my county's behavior health department that our county has a very strict criteria for admitting for psych holds. Like they can't JUST be dangerous in the sense that they wander off or get lost easily but that they run out into traffic. And also they told me that geriatric psych patients are transported a county away which is generally considered a significant strain on older people and I was highly advised to avoid going that route. I was kind of hoping that there is some kind of "script" I can use with her that might influence her to see someone at the ER but it sounds like you're advocating that we use force to hold her. I'm not opposed to that if she really was dangerous to herself or others but I don't think we're there yet!
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Agree, it doesn't sound like you're there. I bet Seroquel or similar might help her a lot. The Zoloft is fine, but while you're waiting for someone else to evaluate her, call this doc's office and tell them you want to add Seroquel, starting with 25 mg at bedtime. It should help her sleep, among other things. If after a week she's not noticeably calmer you can add a morning dose too. But I'm still appalled at how this was handled. You may want to ask specifically for a referral to a geriatric psychiatrist as opposed to a general geriatrician.
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Thought I would update. I think the Gabapentin actually helped A LOT. My mom has been so much happier and less anxious. She's sleeping better and is no longer hiding on the porch or calling all of her friends. She's still very confused, but she's taking it much better. I saw an article in the NYT about the overuse of Gabapentin which does give me pause! But I cannot argue with how much she has improved while using it!
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That's great news, and fortunately it's a pretty safe drug with a wide dose range.. Saw your other thread also and responded there.
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I agree with you on inappropriateness of doc. Outrageous! If the doc wanted to include family input, that should have happened in a discussion with doc so that an informed decision could be made, questions asked. Find a new doc, asap!
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Commonly Used Abbreviations
DH = Dear Husband
DW= Dear Wife, Darling Wife
LO = Loved One
ES = Early Stage
EO = Early Onset
FTD = Frontotemporal Dementia
VD = Vascular Dementia
MC = Memory Care
AL = Assisted Living
POA = Power of Attorney
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