Please help!!! Mother with drug-induced delirium - any alternatives?


Hello, in early May of this year, my 78 year old mother was placed into ICU for acute kidney failure and nearly died. Miraculously, she survived. However, she entered into a vicious state of delirium. (Note: Prior to being admitted to the ICU, her mind was very sharp with no history of Alzheimer's or dementia.) Her delirium was so bad that she was moaning and yelling - so much so that she was kicked out of three rehab centers because she was disturbing other residents. Eventually, after trying almost every drug on the market, she recovered from the delirium and her mental status improved drastically. Unfortunately, with all of the stress she went through during the past three months, she became very weak.

She is now back in a rehab center. About a week ago, she was so frail that my Mom could not swallow her saliva. Her saliva was collecting in her throat and she began choking on it. So three days ago, she was put on a scopolamine patch that dried out her mouth and throat. However, when I heard the word scopolamine, I felt chills go down my spine. From my background as a chemist, I was aware that scopolamine was notorious for inducing delirium. Elderly people are especially sensitive to scopolamine and its family of drugs.

Sure enough, when I saw her the following day after she was put on the scopolamine patch, she began to say weird things (such as dead fish on the counter or talking to her Aunt who passed away several years ago). I realized that she was becoming delirious again. Yesterday, she started that moaning cycle again.

It would be horrible if she were to get back into that intense and vicious state of delirium again. If this were to happen, she would not survive for long. She needs to get off of the scopolamine patch immediately. One doctor recommended ipratropium bromide (aka Atrovent), but this drug is very similar to scopolamine. I am afraid that this drug will push her into delirium again. Does anyone here on this site know of an alternative drug that will dry the mouth and throat without inducing delirium? At this point, my knowledge of medicine has reached a dead end. Thank you.

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Thank you all for your help. I apologize for not replying sooner. This week has been very difficult for me. I am having a h*ll of a time advocating for my mom. Since my two older brothers are physicians, they have been entrusted with making medical decisions for my mom. My suggestions are either ignored or I have to make a fuss to get things done. You may think that having two brothers who are physicians would work to my mom's advantage. However, they are more concerned with her finances than with her health. So, I will leave it at that.

My mom seems to be gaining strength over the last few days. The scopolamine patch is slowly being discontinued. My only concern is her temperature sporadically spikes to around 100 degrees. She tends to become more delirious when this happens. It only complicates matters.

My mom was given the “swallow test” to see if she could eat food, but I believe it was more for determining which type of treatment or facility her insurance would cover. But I am glad you recommended a speech pathologist. Using drugs to treat a health problem should be a possible option, not an exclusive option. I will have to bring that up.

As it turns out, atropine and scopolamine are very closely related drugs. In fact, both are produced by the infamous Deadly Nightshade plant. But I appreciate your suggestion.

blannie and surprise,
Hospice was a blessing when my dad passed away from colon cancer 11 years ago. However, the situation with my mom is incredibly unpredictable. Just last week we thought she was going to pass away. Then, she started to perk up a few days ago. Yesterday, she had a low grade fever. These fluctuations are really starting to make matters difficulty. She has been moved from room-to-room and facility-to-facility so many times. You wouldn’t believe all of the red tape involved. When a doctor happens to see my mom on a good day, the doctor documents that her health status has improved and she gets moved to a different place. Once she is transferred, her health takes another turn. As of now, my brothers (who are the medical decision makers for my mom) have made no arrangements for hospice.

Yesterday, I did consult with a geriatric psychiatrist who knows my mom. He was completely on board with everything I have been trying to express. He does not believe that Alzheimer’s can advance this drastically in such a short period of time. The neurologist (not the geriatric psychiatrist) diagnosed my mom with Alzheimer’s only one month after being admitted to the hospital. Just prior to being admitted to the hospital, my mother’s mind was rather sharp and she easily engaged in conversations. The geriatric psychiatrist confidently concluded with a diagnosis that my mom is suffering from a severe bout of delirium. And given her history of having these extreme bouts of delirium after major surgeries only reaffirms this diagnosis.

I would like to share what the geriatric psychiatrist said about the prevalence of diagnosing elderly patients with Alzheimer’s. He said that he has witnessed a significantly large population of elderly patients are incorrectly diagnosed with Alzheimer’s. In fact, delirium accounts for many of these incorrect diagnoses. Additionally, medications (such as opioids) and other illnesses (such as urinary tract infections) can cause symptoms that resemble Alzheimer’s. I mentioned this because I believe it is important. If scientists are to better manage or cure Alzheimer’s, they need to know which cases are actually Alzheimer’s disease or something else. For example, if large percentage of the elderly population is incorrectly diagnosed with Alzheimer’s, then all the data obtained from this population for research purposes is useless and/or can be interpreted incorrectly.
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When my Husband was on Hospice I was given ..and this is different..
Atropine Sulfate Ophthalmic Solution to dry secretions.
It worked very well with no side effects.
The stuff does not taste great. (I put a drop on my finger just to try) But it did help with the secretions.
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The only thing I have to add is that you might see if you can have a speech pathologist evaluate her swallowing. My daughter is a speech pathologist and works a lot with swallowing issues. She does an evaluation on my mom every couple of months at this point.
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Many people don't realize that hospice can work in a nursing home or other facility. Mthr has been in memory care for 5 years, and hospice has come in to tend to her there. She's graduating Tues because hospice straightened out her meds and stopped her decline with their weekly nursing visits. She has a DNR, but when she fell and broke her arm they used a mobile xray to diagnose. They also treated her pneumonia since it was not related to the primary diagnosis. Hospice has been great, and people use it too late rather than too early. Bring it up in your meeting!

Also, the book Being Mortal by Atul Gawande (and the tv video online, and the article online) deal with end of life decision making. The book goes deeply into nursing homes, and is certainly something to chew on. Honestly, I'd rec your MD brothers read it to benefit their own patients. My DIL at MIT had an opportunity to work with Dr. Gawande in Boston but was unable to accept the job - how we first came to know of his work.
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How is she doing with her oral secretions, Loveumom? Is she still collecting saliva in her mouth?
I agree with what the above posters say; have her evaluated by hospice and talk to your family about it.
The main goal is her comfort. Hospice can help with that as well as so much more.

The delirium remains to a small degree, you said. What besides dc'ing scopolomine was changed?
No doctors are not infallible but if you have a good one and they are on your team are invaluable.
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Two things, first of all, are you working with hospice for your mom? If she's near the end, which you think she is, please consider hospice. They can help you sort through options. And people near the end can have real periods of bouncing back for hours or a day or two before their final demise.

Secondly, I totally agree that doctors don't have all of the answers. My 90-something mom was having a heart procedure and the cardiologist gave her Benadryl (an antihistamine) to make her sleepy and a steroid. Her legs started jerking uncontrollably so that we had to call off the procedure. I'd never seen that before. The cardiologist insisted it was the steroid, but my mom had been on prednisone for years previously with no ill effects. I thought it was the Benadryl and the doc said no. Later, a nurse brought me a printout about Benadryl causing dyskinesia in the elderly. So the doc didn't know what the "h" he was talking about. But the nurse and I did. I immediately switched her to a different cardiologist in the practice, as I didn't like his approach.

I was lucky enough to have worked in a pharmacy years ago, so I saw over and over again the arrogance and ignorance of doctors regarding meds. I will always consult pharmacists over docs when it's a question of medications. And medications and the elderly is an even more specialized field since the elderly metabolize meds differently than younger people. Good luck with your mom...
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Windyridge, When my father passed away 11 years ago from colon cancer, he was at home with hospice. My family stayed next to him until the moment he died. I felt that at least he was in his home and surrounded by family. I don't think my dad would want it any other way.

My mom's case is different. I want her at home as well. My mom always told me that she never wanted to spend her last days in a nursing home. When my brothers suggested that she should remain at the nursing facility, I took that very hard. I was very angry. I felt like they did not respect her wishes. I thought there was no dignity dying in a room at a nursing home. Since then, things have changed. I could not provide my mom the medical care she would need if she were to stay home - even with hospice.

Perhaps one of the best things my mom did was to write out exactly what to do if something were to happen. She did not want a prolonged and miserable end. This was very smart and kind of my mother. She did not want us to feel bad about making a decision that would determine her fate. I am so grateful for that. At the moment, she is not at home, but she is comfortable. Although she's experiencing some delirium, emotionally I feel she is OK.

It's been a roller coaster. Last week, we spent the night with my mom because we thought it was her time. Yesterday, she has been so lively. She is still having issues with delirium, but her facial expressions, her voice, the way she held her head up - she looked very good. My brother just sent me a text saying that our family will meet tomorrow to discuss her plans. I replied "what's happened to mom?" I thought this was it. Instead, he replied that we need to discuss plans because mom has made a lot of progress these past few days.

At this point, I don't have an answer. We have to plan it day by day.
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Love mom , you said in an earlier post that you don't expect your mother to live much longer. Have you considered palliative care or hospice. There's  a lot going on with this poor women. I have to wonder if she were of sound mind if she would want to continue The battle.
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Hello Shane, I did not mention this before, as it is personal, but I have two older brothers who are doctors. You would think this would be an advantage (and in many cases it certainly is), however, it has become a road block for me. Although I am not a practicing clinician, I do have a PhD in Biomedical Sciences. I have more of a molecular view of medicine. Since I do not have the letters M.D. following my name, my opinion seems to mean virtually nothing to practicing physicians. As an example, when my mother went through a severe bout of delirium in the ICU, my brothers, the neurologist, etc., completely ignored my suggestions. For weeks this continued. Everyone who had seen my mom said that they have never seen a case of delirium so severe. As difficult as it was, I finally and firmly told the neurologist his "approach" is not working. He gave in and went along with my "unorthodox approach." Sure enough, she emerged from the delirium. So, I am not completely ignorant of the practice of medicine. My point here is not to denounce physicians, but to illustrate how difficult it has been for me to advocate for my mom.

Getting back, I finally had the nurse at the rehab facility print out a list of her meds. I took the list to my pharmacist (a well-respected, family-owned pharmacy that I have known since I can remember) and he reviewed it. In a nutshell, he said there are too many factors for him to provide a definite conclusion. However, he did point out that scopolamine causes delirium especially in elders.

I must restate that my mom enjoyed a brief remission of delirium until she was administered scopolamine. Prior to being treated in the ICU for acute kidney failure three months ago, my mom was on at least 17 different meds! The doctors took her off most of her meds except the necessities (insulin, two heart meds, blood thinner, etc.). She is not on any new meds, except galantamine (for Alzheimer's) and valproate (for delirium). Since my mom has early Alzheimer's, I don't see a problem with galantamine and neither did the pharmacist. However, she is still taking many meds and who can predict the outcome of polypharmacy. The neurologist put my mom on valproate for her bout of severe delirium. It is used off-label for severe agitation in Alzheimer's patients. It did nothing. Now they are slowly discontinuing it. BTW, about my mom being in the early stage of Alzheimer's, I posted this information in another thread already so I am not going to discuss here.

I liked your suggestion for a geriatric psychiatrist. In fact, I told my brothers early on about having a psychiatrist evaluate her but to no avail. In fact, the "unorthodox" meds (that I told the neurologist to administer to my mom and that ultimately pulled my mom out of the severe delirium) were psychotropic.

But, I am convinced that scopolamine is the culprit. She became delirious again (not to the same degree) shortly after taking scopolamine. It is notorious for its psychological effects. In large (and dangerous) doses, scopolamine can induce hallucinations. As you would expect, there were cases of individuals abusing scopolamine. It used to be sold as an OTC medicine for motion sickness, but now you need a prescription.

The most important part of this lengthy post (sorry) is the following:

Scopolamine is referred to as a first generation antihistamine. There are also second generation antihistamines. The newer second-generation antihistamines cannot enter the brain; whereas, the older first-generation antihistamines do enter the brain. That's why the first generation antihistamines tend to have psychological side-effects (such as delirium) while the second generation antihistamines do not. If anyone is reading this and can provide me with more information about using second generation antihistamines to treat hypersalivation, please reply. I would be grateful.
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It may not be the scopolamine if her dilerium returns no matter what, as you described.

With medications and side effects in the elderly everyone must be vigilant.

But you are saying this is a pattern of hers - she has been asked to leave several facilities prior to this.
Scopolamine may not be the culprit.

Speak with your/ her pharmacist and bring her entire medication list with you and have the pharmacist check for interactions and cross claims - as if she sees many docs they can be prescribing the same class of meds but perhaps a difference in a dose prevents a duplicate entry or another problem to be sorted out. Also if only one MD is writing her prescriptions it's easier to reconcile the meds but when patients see different specialties they add there own prescription and lists are often wrong.

I would focus on trying to get to the cause and get her treatment for her anxiety and calling/moaning out. Is she agitated? Get agitated easily? What precludes these episodes?Is she taking any of the meds for dementia and agitation offered for her symptoms- rispiradel,seroquel et al 

What does she take for her symptoms?

Start with this and take your findings and speak with her current PCP about your concerns.

If you manage to determine that she has no allergy or reaction to scopolamine, I would have her try it once again & see the results. Safely prescribed scopolamine is quite useful to prevent excess saliva in her mouth from collecting and inability to swallow. She may have dysphasia & degree of aspiration. Oxygen helps thus too. 
Realize too that those episodes of feeling like you can't swallow are scary to a patient which leads to anxiety which leads to hypoxia ( gets too anxious to breath), loses oxygen to her organs ( brain,etc) & she will exhibit the moaning & restlessness due to a low oxygen sat. You can purchase your own Pulse Ox and monitor it. Maybe she would do better using oxygen  PRN? Discuss with her PCP if oxygen would be of benefit when she acts out and gets agitated. 
I have heard posters here recommend a geriatric psychiatrist which makes perfect sense. This forum was the first to teach me about geriatric psychiatrists.  I would seek one out in your area & have her evaluated. 

Sometimes the benefits of the medications have to be weighed over the side effects. Scopolamine is very effective in regulating saliva for her.
I am interested in what meds she is currently taking.
Wishing you the best!
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