You Have Dementia – What is it like?

Who doesn’t love a good game of Bingo?  Someone came and asked me if I wanted to play the other day, and I said that sounds like fun.  The gentleman that invited me to play also said there would be prizes for the winners!  What could be better than Bingo and prizes?!?!

I went and picked out a card out of the stack of about 5 that were brought to me and the game quickly started after that.  Number after number was called, and I was getting closer to taking down some money that was being given away as the prize!  Finally B2 was called, “BINGO” I yelled.  No one seemed to care, and everyone kept playing as if I had said nothing.  I know how to play BINGO, and I’ve got a BINGO, why don’t these people understand that?  So I shut my mouth and kept playing, maybe if I get another BINGO, they will understand.  I28 was called and again I had another BINGO so I yelled it again, no response.  What was going on?  Someone told me that’s not how you play this game, I didn’t even know how to respond, so I waited one more time.  Finally G53 was called, certainly someone will hear and listen to me now, I’ve got three BINGO’s on my card - “BINGO” I yelled again.  This time everyone playing wasn’t just ignoring me, somehow I made them all mad.  One actually said “get him out of here”.  I’ve played this game a million times and no one understands and is actually mad at me for saying that I have a bingo?

Put your empathy shoes on and start walking – this is what happens when someone with dementia tries to play a simple game of Blackout Bingo.

Quinine for Leg Cramps

Warfarin 22

Quinine for leg cramps has a boxed warning in the U.S. due to potential for serious side effects like arrhythmias and thrombocytopenia.  In studies, it has been shown to be ineffective for leg cramps in addition to the risks of adverse effects.  I do see it used from time to time.  I’d focus on trying to identify if the cramps are due to another identifiable cause like an electrolyte imbalance (potassium, magnesium etc.), which we can check labs for (patient is on furosemide).  If the pain is more muscle soreness versus cramping, certainly the statin should be ruled out, and I might be inclined to see if a trial of scheduled Tylenol if having pain at night would work.  Seeing the alprazolam at night makes me think the patient has trouble sleeping – another reason to rule out the pain issue, but certainly we need to assess this with the patient.  – Plenty of other things to consider here…feel free if you have something to add!

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Med Rec 101

via USMC
via USMC

Medication reconciliation (often called “med rec”) can be pretty boring, but med rec done right can be lifesaving.  A 89 year old male was hospitalized with a GI bleed and significant anemia.  This patient’s baseline hemoglobin was already in the 10-11 range prior to the GI bleed secondary to chronic kidney disease.  Upon discharge from the hospital, anemia was improving, but hemoglobin was still only around 8.  It was obvious from reading the progress notes from that hospital stay, that his aspirin was not going to be continued due to GI bleed risk.  On the discharge medication reconciliation form, the aspirin was checked to be discontinued.  What the staff didn’t realize was that this form had changed and when I checked the active medication list, this patient was still receiving the aspirin.  This had slipped by two healthcare professionals because their med rec form had changed (i.e. they weren’ t used to identifying the medication orders on that new form).  This patient did end up receiving the aspirin for a couple weeks, fortunately without issue.  It is very easy to get into “auto-pilot” mode, but we must think critically at all times!

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Treating Dementia Related Behaviors

Photo via Ahmet Demirel
Photo via Ahmet Demirel

This is arguably one of the greatest challenges in the elderly.  I nearly daily get asked questions about behaviors associated with dementia.  Often these patients can be aggressive, hit, spit, kick, swear, hallucinate, be sexually inappropriate, or have delusions.  I was once asked what the best medication is to treat these behaviors.  I relate that question to what is the best antibiotic to use.  If there was one miracle medication that worked, every patient would be on it.   It really depends upon what you are trying to treat, and often we can do an adequate job of treating these behaviors without medications or at least by thorough assessment of the patient in identifying the root cause of the behavior.

There are many questions to ask when assessing new or abnormal behavioral symptoms.  Here’s just a few to focus on from the start:

1. Identify the specific behaviors and be sure to relay this information to the clinicians/caregivers who are helping in making decisions.

2.  When did these behaviors start and what time(s) of the day do they happen?

3.  Can we correlate the start of new behaviors to anything else? (i.e. fall, medication, stroke, family crisis, infection, change in environmental factors etc.)

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Zoloft (sertraline) and Loose Stools

robin williams picIn light of some recent awareness about mental health issues with the tragic passing of Robin Williams, I’ve decided to give you all a mental health related case study on one of the challenges in treating depression.  57 year old patient diagnosed with depression and was initiated on Zoloft (sertraline) 50 mg daily.  The physician in this case felt the patient was very depressed, and wanted to titrate the dose up fairly quickly.  Zoloft was increased to 100 mg daily after two weeks, and then further to 150 mg two weeks after that.  Remember that patient adherence to medication especially antidepressant therapy can be challenging due to the fact that most patients are not going to experience any relief in their depressive symptoms on a short term basis.  However, the side effects from antidepressant therapy can be apparent immediately upon starting the medication.  A couple days after the increase to 100 mg daily, the patient began experiencing troubling loose stools, multiple times per day.  Patients are usually very perceptive to side effects of medications especially when the timing initiation of the medication and the onset of the side effects correlate.  This patient ended up stopping the Zoloft on their own due to the intolerable side effects and refusing further antidepressant therapy.

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Medication Management and CKD

via Canadian Diabetes Association Clinical Practice Guidelines Expert Committee
via Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

78 year old male on a hefty list of medications.  The major issue to resolve was a rash that had started about 3-4 weeks ago and was spreading nearly all over the body.  I was asked to help out with the case by looking over the meds.  There had already been a couple of meds held to rule out the rash being drug induced.  In medication management, the first place to look when new symptoms happen is the changes that had been made previously to the new symptoms.  In this case, Lasix (furosemide) had been increased and Zoloft (sertraline) had been started within the last few months.  Both had been held for over a week, and it was felt as if the rash was not improving.  At this point, the primary provider did not feel as if it was medication related and was searching for other diagnosis and dermatology involvement.  Not so fast.  What was noted was that this patient had chronic kidney disease (CKD) and the kidney function had been changing over the previous few years labs and that the baseline creatinine had gone from about 1.2-1.5 range and was now consistently above 2.  Estimated GFR had dropped between 20-30 points.  Amongst the massive medication list, a seemingly innocent dose of allopurinol 300 mg daily was hiding.  Remember that allopurinol is cleared by the kidney and with the worsening kidney function, this drug was sure to be at higher concentrations in the body than it was years ago.  The allopurinol was held and a low dose of colchicine 0.3 mg daily was initiated without issue.  (Remember that colchicine needs to be dose adjusted as well).  The rash began to resolve over time and all was well again!

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Antiplatelet Therapy – Med List Review

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I’m going to cover a couple points tonight, and let you guys help with anything else you’d be concerned about by looking at the med list!

The morphine dose certainly needs to be clarified, and along with that we might as well ask how frequently it is used for chest pain.  Along with the potential for chest pain and cardiac type medications, it is pretty suspicious that this patient is not on an antiplatelet of any kind?  Maybe bleeding risk history? Frequent falls potentially Parkinson’s with Sinemet Rx?

The other point I will mention is that this patient is on a fairly substantial dose of insulin – so we certainly need to pay close attention to blood sugars  and any abnormal symptoms as this patient likely has dementia being on the Namenda.  Hypoglycemia identification can often be a challenge in dementia.

Definitely a couple other things to monitor and point out here…thanks for your help in advance!

Drug Induced Edema

via articles-home.org
via articles-home.org

 

A 64 year old male patient was struggling with blood pressure management, usually running in the 160′s range (systolic).  He was already taking lisinopril 40 mg daily and had failed at implementing lifestyle changes up to this point.  Procardia (nifedipine extended release) 30 mg daily was added to this patient’s regimen.  It had minimal effect and  the patient was slowly titrated up to a dose of 120 mg daily.  This had dropped the blood pressure 10-20 points on average, but the patient refused to continue to take the medication due to bothersome significant edema.  This patient was successfully transitioned to a beta-blocker as well as a low dose thiazide diuretic for blood pressure management.  Calcium channel blockers are effective at lowering blood pressure, but are also one of the more common medication causes of edema especially at higher doses.

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If It’s Not Broke, Don’t Fix It – Defining Polypharmacy

via cancergrace.org
via cancergrace.org

I appreciate all of your comments on the site!  An engaging, interprofessional audience really helps enhance the learning environment.  I recently received this comment on a recent diabetes med list review I posted: via Leo Lawless - “While the comment on the dosing schedule for Actos and Oxybutynin are valid we need keep in mind that manufacturers recommended dosing schedules are not a bible and we are treating people and need look at their individual response to a varied schedule. If its not broken don’t try to fix it,”  The comment is very thoughtful and absolutely true as well, and there is no textbook on how to manage patients’ medications because there a literally hundreds to thousands of variables that can affect medication management.  For me personally, I’m going to lean in and attempt to investigate how and why this patient ended up on twice daily Actos and Ditropan patch once weekly.  If the primary provider has no idea (or can’t remember), and the patient doesn’t know why either, I’m in the camp that is probably going to attempt to take some risk to reduce medication burden by consolidating the Actos (pioglitazone), monitoring blood sugars as well as closely assess the patient’s urinary symptoms and recommend a trial hold of the Ditropan patch to minimize anticholinergic burden going forward.  If the patient is adamant that the medications are working well, well tolerated, and have improved their diabetes, urinary symptoms, and overall well being, of course I wouldn’t suggest any changes.

I wanted to use this comment to demonstrate that it can be challenging to address medication related problems, and even more challenging to address them when everything is going fine with our patients.  I believe the “If It’s Not Broke, Don’t Fix It” philosophy is one of the major culprits that leads to polypharmacy.  At what point does too many medications actually become “too many medications”?  If the patient is on 52 medications is that too many?  If they feel perfectly fine on 52 medications and are doing well should we not reduce or change anything?  If a patient is on two medications that do the same thing, but are doing fine should we leave it alone?  Every patient brings a whole set of new circumstances that has to be considered.  “What is polypharmacy?” depends upon the provider, depends upon the patient, and is a question that each healthcare professional has to find a comfort level with.

For me, I work primarily in geriatrics and when I hear, “if it’s not broke, don’t fix it” – I can feel polypharmacy creeping in.  It’s a mindset that is easy to have, but I do not believe it is the best mindset for the majority of my patients.  – Notice how I said “majority” – not all :)

Healthcare professionals disagree, and I would make that argument that if there is no disagreement, there’s no critical thinking happening.  I have had the unique opportunity to make recommendations to well over 100+ different providers/healthcare professionals and while I feel I do my job in a consistent manner, there are providers that agree with nearly everything I suggest, and there are providers that disagree with many of my recommendations, and I’m ok with that.  What’s your philosophy?

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After a C. Diff. Infection

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78 year old male living in a long term care facility was recently treated with a couple of different courses of antibiotics to treat recurrent respiratory infections.  Treatment was eventually successful, but a few days following the final treatment with antibiotics, diarrhea started to develop.  It started out fairly mild but was progressing to several loose stools per day.  The physician was notified of the diarrhea and nurses had wondered if Imodium would help resolve the issues.  Imodium 2 mg twice daily was prescribed, with additional doses after each loose stool (up to a max of 16 mg/day).  Even with Imodium, the loose stools did not completely resolve.  C. Diff. testing was performed and it was indeed positive.  The resident was treated with metronidazole which was successful.  Diarrhea was 100% resolved and the resident was without any lingering symptoms.  In the effort and justified concern with treating the C. Diff infection, what was forgotten about was that the resident was still on the Imodium months after the C. Diff. has been treated.  The lesson here is to remember avoid long term medication use for an obvious short term problem that resolved with treatment.

Interprofessional Medication Education