I have to make some decisions as to starting two new medications for my Mom. Any advice?
She has Dementia but these are not Dementia drugs per-se. I am my Mother's Primary and only caregiver. Mom has Dementia... to the point of not talking much, not eating much, drinks a little tea and chocolate milk. She is starting to have a hard time swallowing her pills. Chocolate Milk works better than water, and breaking up 4 pills into having her take two pills at a time seems to help. None of the pills are very large. She is 80 and started to have a large decline this past November (2015). She is physically weak and needs help getting up the 8 steps to the level of the house the bedrooms are on (The house is a Tri-level). She is shaky and she is frail. She was NOT this way until she had her first fall, in the bathroom on Saturday December 12th. I did have a Hospice RN come to help me get her up. This is the first fall and I don't have a medical background. The Hospice RN and I got her to bed. The RN checked her over and said nothing was broken- she would be sore but should be OK. The RN took her BP- was 112/42, the RN did not like the 42 said it was low. She also took a pulse ox reading the O2 was in the mid 80's. She said it should be 90 or better. She ordered a walker and a wheel chair. Mom used the walker on Thursday but seems to be a bit stronger these last couple days and doesn't use the walker. Mom really needed it on Thursday.
Mom has Vertigo and can no longer express when she is dizzy. She has taken a med called Meclizine for years and it always works great. Mom also has had high blood pressure that is in the normal range with medications and has been stable since January 2014. She takes Atenonol, Lispironil and Hydrochlorothaizide. She has been taking Diazepam at bedtime for a few years... it DID help with sleep. Early last month she started to go to bed earlier and then get up a few hours later and think it was the next day (even though it was dark outside). After awhile this happened every night. Her PCP (a very good Hospice MD that deals mostly with the elderly) started her on Trazodone (a SNRI Antidepressant) 50 mg to be given at 8 pm.. this was to help with the waking up and thinking it was daylight when it was dark. This has worked very well.
Mom has been on Aricept since June of 2013 - she had a different PCP then- There was trouble increasing her Aricept from 5 to 10 mgs. She had physical side effects. Eventually she was getting very aggressive with me and finally went to 10 mgs. That helped with the aggression. Next she was to start Namenda XR (for the PCP she had - that PCP left the clinic to work in a hospital setting this past fall). Namenda XR was not a good med for her- once again the side effects. She had bad side effects so she was taken off of it.
The Aricept was recently stopped as the Hospice RN that came the night of Mom's Fall discussed it with Mom's Hospice Dr who is also her PCP. Our Weekly Hospice RN came last Wednesday and said we can stop the Aricept.
So her meds right now are in the AM Atenonol, Lisinopril, Hydrochlorothiazide, 1 Tylenol, and 1 Meclizine. In evening by 8 PM she has Diazepam, Trazodone, 1 Tylenol and 1 Meclizine. Note: I started giving her 1 Meclizine AM and PM since she fell. Prior to her fall she did not take Meclizine on a regular basis -it is written "as needed".
There are to be two new prescriptions written that will be filled tomorrow. As Mom ages she is very physically touchy with new meds.
1 med is Remeron (a SNRI Antidepressant that usually leads to weight gain) to help with her appetite. I think this may be alright - as she does not want to eat much ever. The 2nd med is the one that I wonder about-- which is Norco for pain. Mom has not been grimacing, verbally saying oww, or moaning. She is not laying in bed for hours and never getting up. I think Norco might have been helpful for the day's immediately following her fall (December 12.) It's been 9 days since she fell so why Norco now- sounds like she will be taking them everyday. Had her PCP or an RN did a through examination and saw evidence (things an non-medical person could not see) I would be more confident about the Norco. Norco is a narcotic med for moderate to severe pain....
On the other hand she has lost the ability express pain to me verbally either - although I have heard an oww in the past.
Anyone have any thoughts? Am I just being hyper-vigilant about this?
(PS She has Hospice for Palliative care-- she is not to the point of needing Hospice yet- she has a very non-aggressive Ovarian Cancer- has not changed in size or spread since it was found on a CT Scan in February of this year. Took us totally by surprise as she was very vocal then and never had pain. She refused to have surgery for the cancer. Its her body and her life.. I respect her choice)
I don't see them keeping her on the Norco for very long... she is hurting when she tries to get up from a sitting position... no words but the look on her face tell me and the Hospice people what she is really feeling. I am all for Tylenol and have nothing other than that in the house. We stopped taking NSAIDs unless it is absolutely necessary (last resort).
The Trazodone is a big help - it helps her sleep for the night and she is not getting up at midnight thinking it is noon. Pitch Black outside but she's convinced it is noon... OK Mom whatever you say.. I'll pick my battles with her for something seriously important.
The Remeron got filled but I didn't start it... Started with the Norco- just starting with one medication at a time - to see what type of side effects might happen. I am not giving it 3 times and a 4th time at bedtime if necessary. RN today said it was good to start her off with twice a day and see how it goes. If she needs it, really needs it I certainly will give it to her. Not too sure about the Remeron... it is the smallest dose they make.. but will have to think on that one a bit. I do have a bit of experience with antidepressant and psyche type drugs...I was diagnosed with Major Depressive Disorder many years ago (lived in a populated area then and still do- but I am here at our second home taking care of Mom right now)... it took almost 9 years to find the right medication combination that would work for me. None of the SSRI's at the time (and there were many of them) gave a response. Wellbutrin was a very good partial response and then a small dose of Adderall was added. Together they make up my antidepressant. These last few years it has been Wellbutrin and Vyvanse. Our second home is in my mom's home town it's very rural (more like a forest) nearest hospital is about ~ 40 min. Not an abundance of Doctors in this area of the state either. So it's not like living in a populated area where a person has several different Dr's and others working as a team. I have only one treatment team and that team is Hospice. I have dealt with Hospice before, when my brother was dying (complications from MS). This was in another part of the state. They were very good and the Hospice I am dealing with right now they are very good also. As I told Ferris1 we are using Senokot-S to keep the stool soft and combat constipation. If that proves not to be what is needed the Hospice RN and MD will help find something else that does the job without being overly harsh.
Her pulse ox numbers are back in the mid to high 90's it was in the 80's when it was taken right after her fall. She has no lung problems - non smoker.
Thanks so much for your reply.
JessieBelle: First of all Thank You for your reply. I totally agree with what you said about her blood pressure...We went through a time back in 2012 where Mom's BP started to become very high. She had been to see her PA because her lower back hurt. Scripts for Ultram and Ibuprofen 600 mgs were written.. Not long after that her blood pressure started to climb...Was not long and the Ultram was gone but the Ibuprofen was still in on her list of meds. Ibuprofen can have an effect on her BP meds. Here are her blood pressures from that time:
MOM’S BP FACTS
11/22/13 BP 176/74 Ultram 50 mg 1 tab every 4 to 6 hrs IBUPROFEN 600 1 EVERY 6
12/03/13 BP 177/83 IBUPROFEN 600 1 EVERY 6
12/17/13 BP 179/99 Same as above
12/20/13 BP 207/91 Same as above
12/23/13 BP 156/66 IBUPROFEN STOPPED AT MY REQUEST – TYLENOL INSTEAD
1/17/14 BP 135/72 BP meds are the same as now
3/8/14 BP 116/62 BP Meds are the same as now
Her blood pressure stayed near the normal range since March 2014. Had I not spoke up to the PA about the Ibuprofen would her blood pressure ever came down? I am no genius I just know how to research the Internet.
I can assure everyone that has replied that I have already started taking corrective action as her RN was here today. We discussed the HCTZ - she said take her off for awhile and watch her blood pressure. If it stays low then the Dr will likely remove one of the two remaining BP meds. I think the HCTZ is not appropriate- BP is low and she is not drinking as much as she did. Seems to lend itself to possible/probable dehydration.
As far as the Hospital Bed... this could be a plan BUT a question is, how will Mom feel about it? Some people will say too bad she will have to do it BUT I SAY she is my Mother and her feelings will be considered in this situation. Doesn’t mean the situation will go the way she wants but it does mean I will take her feelings into account. There will likely come a time in the future that I will have to do things that she is not going to be happy about. Sad part is she does not really understand many of the things in her life now. This will be a Major change. I’ll be talking to her Hospice group about the Hospital Bed
Considering your Mom is still at least somewhat ambulatory, I'm surprised they're adding the Norco. That will DEFINITELY add to her dizziness!!! If it were me, where she's not showing any clear signs of discomfort, I'd be inclined to give Tylenol & Motrin on an alternating schedule...Tylenol every 4 hours & Motrin every 6 hrs. Both are available in liquid form, too, which would be easier for Mom to take...and neither one has sedating effects or would increase her vertigo.
Just to add to Leah's point about crushing - as well as the modified release formats which dispense their contents over a protracted period of time, some others such as PPIs have to get past the stomach undigested to work - so do check the patient information leaflet before you crush, or ask your pharmacist. There's usually a way round swallowing difficulties so it's worth finding out.
You are right to be vigilant, never apologise for that. I hope these new meds prove helpful to your mother, best wishes to you.
God bless you through this journey. Definitely enjoy her while you have her. Please take time for yourself..it's ok to enjoy the Holiday Season & include her with what you feel you both she can handle.
Her BP is really low, that can contribute to dizziness---I'd also question the need for HPB medication at this point.
That is a low dose of Trazadone, but if is helps her sleep....also the antivert makes many people drowsy (altho it is the first line of defense for chronic dizziness). What dose of Norco? That is hydrocodone and Tylenol, and can be a pretty potent pain reliever if she's in pain, BUT she's on so many other drugs that can cause dizziness--I'd definitely talk to the pharmacist (no offense to drs, but I have gotten my BEST medicine usage advice from Pharmacists!) The Remeron seems almost pointless, if she is eating so little now, its side effect of weight gain is only in those who take it and then eat more--most "weight gain" side effects from SNRI's are anecdotal anyway and we're talking 2-3 lbs, not 20.
Gosh--at this point I would try to keep her comfortable and let her sleep as much as she wants. It's scary to see someone go downhill at a rapid rate, but that is often what happens. Listen to Hospice, if they are a part of your team. It may be time to simply use palliative care and let nature take its course.
Good luck with all this---
Ferris1 summarizes well. I believe she is a retired RN as I am. The less meds the better. Here is what I learned with my parents' trip through this dementia....
1. At a certain point it does not help to stay on the Aricept and Namenda
2. Meds that are constipating DO cut down on the desire to eat, and cause other problems. If pain has let up from the fall, ask why not switch to tylenol or advil...as non narcotics. If narcotic is needed, give it with colace to keep the stool soft so it will pass through easier, or you will get into issues of needing laxative or enemas which really disrupts intestinal functioning.
3. I agree with asking for a trial of taking away at least a couple of the blood pressure meds....as too low of a blood pressure causes dizziness by itself....aside from also having other meds on board that cause dizziness and a diagnosis of vertigo as well.
4. I would keep Mom walking with the walker all the time, especially since you say the dizziness/vertigo comes on without warning. Falling can always cause a break in older people, and with dementia, creating a habit of safety usage is much easier for the brain than the notion of we'll use it today, but we don't need it tomorrow.... for the same reason, I also agree with thinking about moving the bed downstairs, or creating a way that all her 'living' is on one level....in anticipation of her getting weaker over time. The real key here is to be anticipating the need for increased safety before the fall or the need for more support.
5. My Dad was on the Trazadone to help him sleep longer at night and it worked well. I recommend printing out a list of all prescribed meds to give to ALL doctors regularly, because as the elderly get into such an array of drugs prescribed....some are contraindicated with others, especially among the antidepressant and other psych type drugs....and any one doctor may not have knowledge of one another ordered, if YOU are not extra careful to tell them about every drug. Sometimes, just seeing a list, helps them see that certain things could be discontinued or at least cause a better assessment of everything going on.
6. The appetite issue and having problems with swallowing, needs to be considered carefully....how and what to feed, how to provide what Mom especially enjoys, to get her to eat enough, and an awareness that nutrition is important for energy and strength to 'keep on keeping on'. Also, what is the reason for the low pulse ox numbers....her level of oxygen in her blood is also important to not being dizzy and falling and for her brain to be functioning as well as possible.....so YES that number needs to be up above 90%....mid 90's are considered normal, if there is no chronic lung condition. I am glad that hospice is involved and that you have acess to their RN to help assess and recommend things to discuss with the doctors. I do think you need to be vigilant over all the drugs and medical stuff....not because you'll get her better, because as ferris1 says, there IS no cure or fix for dementia, but you want to maintain her abilities as long as possible, so her days can be as positive as can be for as long as possible. Use your resources via hospice as they are generally wonderful people to have on your treatment team.
It sounds like Remeron is being suggested the same way Trazodone is -- for its side-effects rather than its primary purpose. Would eating a bit more and gaining a little weight add to her comfort level?
I have no medical training. Most of us on this board do not. (A few do.) I am reacting just from my own experience. I see no harm in trying these two medications and watching carefully for side effects. (For that reason I would NOT start the two at the same time. How would you know which one caused a side-effect?) If they don't work or cause side effects, just ask the doctor to stop them.
If swallowing pills is difficult for Mom, you really don't want to add anything that doesn't contribute to her comfort. But how will you know without trying.