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So, here's the cast of characters...
1. My brother and I, both out of state
2. Dad, in Massachusetts, 91, in assisted living, with Parkinson's, moderate cognitive issues, and depression. Already on some meds, and on Medicare (not Medicaid)
3. Stepmom, 88, living at home in Mass., with cancer (although doing better overall than Dad)
4. NP, the Nurse Practitioner who's seen my dad several times already
5. GP, Dad's doctor, who sees him all of about 15min four times a year. Somewhat contentious relationship between him and Dad.
6. Exec, the executive director of the Assisted Living facility.


So, Dad's been in AL for almost two months. NP visited him about a month ago (has seen him 3x, I think), and seemed to develop a good rapport. Initially, she mentioned having a psychiatrist colleague to come in and work with Dad and also test his cognitive capabilities.
She has since mentioned some suggested changes to his meds to reduce his depression and his anxiety (notably because his wife his not living with him). However, she has noted that, because she's an NP, she can only suggest medication changes.
NP did bring in a psychiatrist, who ran some tests. I have a copy of those results. He also suggested that Dad's health care proxy be invoked (putting me in charge). Those results have also been sent to the GP.
GP appears comfortable letting a psychiatrist make changes to the meds; I have not spoken to GP firsthand, but we have a woman who's been helping out there with both Dad and stepmom who has spoken to him.


Exec told us a 'registered therapist' saw Dad (and stepmom) this past week, and will continue to see Dad regularly. However, not clear she's an actual psychiatrist.


My brother and I think what Dad needs is regular psychiatric help and some changes to his meds, but aren't sure how to make that happen.


I plan to call GP regarding the psychiatrist's recommendation about the health care proxy, but am not sure what else to do to make all this happen.


Suggestions?

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Adam, you have a lot of obstacles in your path but I think you were given some great advice here. In my opinion, being an advocate for your dad just shows how much you truly love him and just want the best life for him as possible. Best wishes.
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Rosebush: Yes, we had considered having the neurologist help here--I recently sent him the test results. As far as stepmom, she has no plans to move into assisted living unless her health takes a drastic turn for the worse (a plan I don't think her kids are thrilled with). She is likely to move closer to Dad before the winter, however, possibly a small apartment (ironically, which will raise her monthly living expenses).
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Adambravo, I commend you for advocating on behalf of your parents. I know your intentions are not to cure your dad but to give him a better quality of life. Good for you. I have no experience with any physicatric issues but know once the GP referred my mom to a neurologist, the neurologist was the one prescribing the majority of the medications and he basically became the primary doctor. Is there any chance your mom would be able to move into the AL facility with dad? I don't need an answer, just a thought. Good luck
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Navlady: A psychiatrist is the doctor who listens briefly and is the medication prescriber. A psychologist is the doctor who listens in great detail and is NOT able to dispense meds.
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: The responses are all so valid and truly worth you being involved with the medical decisions that are being passed forth. It is your responsibility to see that your parent is being well taken care of medically, emotionally, medicinally as to his needs. Try all you can to be involved. Sincerely
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Eldercarewiz: Thanks for all the insight. To some of your questions/input...
1. "Funny the primary care NP told you they can't write Rx's" The PCP seems to support this notion, referring to her as a 'consultant'. Dad's neurologist's assistant, however, was surprised at this as well--perhaps it's a restriction from Medoptions, her employer.
2. "If your dad is early in the process and you want more info on his baseline memory/cognitve functioning - I would suggest you see a neuropsychologist for further testing & diagnosis." A psychologist (not a psychiatrist) from Medoptions did a full workup which was faxed to the PCP and neurologist (and I have a copy as well).
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One thing with Minneapolis, the Geriatric Psychiatrists are few and far between and hard to find and they do not visit nursing homes on demand. Some are affiliated with certain nursing homes only, some are with managed care groups, and the remaining see patients in the office with a long wait time for getting into pretty full practices, so its not possible everywhere to just bring in that ideal geriatric psychiatrist when you want it. They are wonderful assets when you can find them for the meds, though.
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adambravo - I'm not quite sure what your looking for so I'll just tell my experience in a similar situation. My mom had been living in IL. She was really starting to struggle with things but I had no experience with dementia and knew very little about it. Mom was becoming increasingly difficult to reason with, wouldnt take her meds, becoming mean and verbally abusive - but mom has always been on the eccentric side...Mom fell in late August, no real injury but for some mysterious reason the fall kicked her dementia into high gear. In about ten weeks mom went from IL to hospital to rehab to AL to NH. By the time mom went to the NH she had become a complete nightmare and I was teetering on the edge of mental collapse trying to deal with her. I went to see my own dr for help with my own stress and anxiety. I had also found this site. Here, I had seen mention of Gereatric Psychitrists. Then my dr suggested the same for my mom. I got my moms own PCP to make a referral - a needed step with moms insurance - she is also on Medicare. During the Psy visit my mom was tested for dementia. The Psy then did a complete overhaul of my moms meds. It took about a month to get all the med changes in effect as stuff needed to be stopped and started gradually. After the month there was a marked difference. Yes, mom still has dementia but she is now calm, less anxious, non-hostile and 100x easier to be around. Mom is even a bit more focused in her thinking. Honestly, I don't think where she was living would have continued to let her stay if this hadn't worked - and I doubt I would have continued to be her DPOA and health care proxy. Sooo - if I were you, I wouldn't tippy-toe around with wondering who's doing what. I'd get your dad seen by a qualified Gereatric Psychitrist - and I'd do it as soon as I possibly could.
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When you call the GP, have the names and "initials" for each of these people in front of you and written down (eg. Susan Smith, Masters in Social Work or John Jones, MD. Board Certified psychiatry or Mary Martin PhD Clinical Psychologist). Sounds as if you are clear that you want them to try more effective meds for depression and anxiety? And that you want someone to act on recommendations already made. Be clear on what you want, and be clear on who is in the picture as step one. It can be quite a mixture of compartmentalized job descriptions, and each location functions in its own way. In my own family, the experienced Nurse Practitioner for the facility (who is supervised by an Internal Medicine MD) has been the best at choosing and prescribing psych meds because her entire practice is nursing homes. If its antianxiety, antidepressants, and antipsychotics, these are the everyday arena of ALs and nursing homes.
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So what exactly do you want to accomplish? With Parkinson's, depression, being 91 yrs. with dementia and being without his wife, taking a different "pill" is not going to change his prognosis. I know you want to rush in and "fix" him, but you need to start letting go as his disease process continues. Keep in touch with all concerned and try to see him in person as much as you can. You will not have him forever. Best wishes!
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I do the psych social work consults in AL here in western Mass - they might do things differently where your dad is living but keep in mind the regulations have some grey areas especially when it comes to how much case management (calls to PCP/GP & other providers, coordinating care & info etc.) they are willing to do. That's where family come in and you are right to get up to speed on how their psych consultations work.

I work with a psychiatric nurse practitioner who does the meds and I do the therapy or behavioral planning on dementia unit. We are both there one day per week - sometimes two. Usually when the NP sees someone & she has a recommendation the staff fax her note to the doctor and keep any responses to share with her when she comes back the next week. She really goes above and beyond what most psych prescribers do - she will speak to the PCP office if needed. Then the PCP writes the order which then gets faxed to the pharmacy but my NP now has a prescription pad for any doctor that does not want to touch the psych meds at all. This is a new development for our team so I am not sure any other psych consultants are doing this but it doesn't hurt to ask. Funny the primary care NP told you they can't write Rx's - I thought that is what differentiated them from RNs? Perhaps she meant discomfort with psych meds?

Either way - I have found that thought even they are able to do so - more and more doctors in primary care do not want to touch the psych meds - esp for dementia/alzheimer's. Understandable - managing psych meds are a delicate process which needs a slow and careful approach fully integrated with the therapist seeing your dad. When I am working with someone - it's my visits that give vital info on whether the meds are working according to staff and my observations.

If your dad is early in the process and you want more info on his baseline memory/cognitve functioning - I would suggest you see a neuropsychologist for further testing & diagnosis. It's a rare but often the better neurologists that will prescribe the meds your PCP isn't comfortable with - but in my experience neurologist are better suited to manage movement disorders like parkinsons but not mental health.

Bottom line is the psychiatrist should be the one managing his meds (not just doing testing) along with the therapist working in concert to meet the goals you set as his HCP. In facilities where they do medication assistance - staff will help the process along but it is slow and they have many people to care for.

If you want some more help with this - I would ask the woman (certified care manager I hope!) you have hired if she provides this type of clinical case management. If you can afford to have her do it and she is qualified - then she becomes the point person to make sure everyone is on the same page (psychiatrist, therapist, GP, faculty staff, you and any other caregivers involved). Saves a lot of time and hassle for you and since she would know the system better - the hope is that outcomes will be better having her in charge.

Hope that helps!
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My brother appears to be somewhat skeptical of having a nurse-practitioner therapist suggest medications vs an actual psychiatrist; I don't have a strong opinion one way or another. Theoretically, we think that Dad's neurologist might be able to get the meds; his primary care physician is pretty much staying out of things.
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The psychiatrist may have recommended a therapist. Usually insurances do not want to pay psychiatrists for therapy, only assessments and medication management. Just because he is seeing a therapist does not mean the psychiatrist will not return to monitor any psychiatric medications. Usually they go hand-in-hand.
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As long as the registered therapist is approved by the psychiatrist and they stay on the same page, it should work out OK. Ask the psychiatrist if they are willing to work with the therapist.
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