Expert: Michalene Peticca - 6/28/2007

Question
Hi Michalene,

I am trying to help family sort through a serious problem beleaguering one of
our prized Aunties. She is 87, and really in quite good health for her age. She
is still quite independent, living in an independent living facility. I was just at
her apartment yesterday and it was SPOTLESS. She is spotless herself and
really, other than this ongoing, progressing mental health issue which I will
describe below, she is doing just fine.

Here’s the thing… about a year ago, she started having trouble sleeping due
to nightmares about people being in her bedroom with her. These nightmares
have progressed now to full-blown waking delusions. Extremely paranoid,
she is convinced there is a man, a woman and a little girl conspiring to keep
her awake by peeing on her bed or spraying her with pee, which she calls
‘sass.’ It’s terrifying her and she’s convinced they’re trying to keep her awake
so that she will fall down and hurt herself due to being tired and scared. I
must point out that she has lived alone since 1976 when her husband died.
She actually likes to be alone, which I think is part of her problem. She is also
deaf and has been since around the age of 65. This is one of the many ways
we can confirm her experiences are delusional. However, as soon as we
remove her from her apartment and bring us back with us, she is fine as soon
as she calms down.

When this all began, her G.P. prescribed an antidepressant (Zoloft). That really
didn’t seem to help at all, so after a few months that was discontinued. We all
agree she shows no signs of clinical depression (no change in behavior, not
isolating herself, still likes to do all the normal things). Then we brought her
to a psychiatrist who prescribed Aricept, the Alzheimer’s drug. Again, I don’t
agree with that diagnosis, because she shows no memory problems,
aggressiveness, etc. Just the delusions! Just recently, we brought her to
another psychiatrist and he prescribed Risperdal, which I think was more on
track with her symptoms, but it seems to have actually made things worse.
Over the weekend she begged to be brought to the ER because I think she
was having a panic attack. They did a brain scan there and didn’t find
anything (though none of the ER staff were Neuros, nor did they bother to
consult one). They sent her home.

Given her age, I would be fine with the psychiatrist who treated her for some
form of Alzheimer’s if she had any other symptoms beside the delusions.
However, that’s all she has! Her memory is just fine, she has not changed any
behaviors and practices in several years. As I said before, her house is
spotless (so spotless it doesn’t even hint at the fact that an elderly person
lives there… it smells nothing but clean), she cares for herself quite
thoroughly (always looks clean, coiffed and well-dressed), goes to church,
calls people, smiles and enjoys life. She has reported no depression. Her only
difficulty with sleeping are these ‘people’ harassing her.

This is all very frustrating. And, being well-versed in the medical world, I
know that patients who are not caucasian, and especially those that are black
tend to be dismissed and/or ignored by health professionals. I myself, not
being a blood relative, am not black (as far as I know), but I have experienced
this well-studied issue while standing beside my loved ones who are black. I
am beginning to think this is the case here (she is of mixed race). Regardless,
I’m sort of at a loss as to how to proceed. We took her to another psychiatrist
today and he just wanted her back on the Aricept. It wasn’t working, and we
really couldn’t nail him down on why he thought she should be back on
Aricept. He did prescribe her Klonipin for her anxiety at least. We’re going to
keep her on the Risperdal with the Klonipin for a few more days to see how
things go.

Thoughts? I’m doing some web research and discovering that her problem
may simply be due to her lack of external stimulation. Though it’s not really
her personality, I think she’s going to have to spend much more time with
other people. I’m also going to suggest that the family get her a hearing aid
and integrate any other items in to her lifestyle that will increase stimulation.

Thanks in advance.


Answer
Tamara,
Hello!  First let me apologize for this answer being so tardy.  I just received notification from All experts that a question was waiting for me. I think something happened in their computer system.  Thank you for your patience.

This is a very interesting situation, although i am sure it is quite frustrating for your family to not have an exact answer.

I am not a physician; however, from my education and experiences, i would agree that it is NOT Alzheimer's or a dementia related disease.  You would certainly see other manifestations of memory loss, physical changes, behavior/personality changes.  

Indeed, you are correct in assuming it is related to a delirium.  The question is what is causing the delirium.

It may be the deafness, i personally have not worked with fully deaf individuals, but i do know that an elder person who is hard of hearing or poor vision has severe perceptual differences of their actual environment.   So, therefore, what may your Aunt be "misperceiving" at nightime?  Does she leave the TV on when she sleeps? the radio?  Any pictures or objects in her room that may be causing the delirium?   For this answer, pretend to be your aunt and turn the lights out and put cotton in your ears...anything happen?    

Contact the local agency for Deaf and see if the elderly do have some delirium from hearing loss.  

OK, let's say it's not related to the hearing.  I would certainly go to a Primary care physican and have an extensive Blood profile work-up.   Could your aunt be having a diabetic type reaction at nightime?  This may cause delirium.   Is she running a low infection somewhere ....delirum is more prominent at night due to infections.     Anyway, i would strongly suggest pursuing this as an elimination.

Lastly, i do agree that if neither of these are the cause for your Aunt's behavior...it appears being with others is calming for her.   Perhaps more interaction with others, especially more exercise and more daytime activities to make her more tired at night and therefore, perhaps sleeping deeper and longer.  (Nursing homes finally realized this years ago, that it ISN'T good to let folks sleep all day because they will be up All night!)

And you know Tamara...has anyone asked your Aunt if she is worried about anything? Being 87, she just may be afraid of not waking up in the morning.  It is very common and many elderly develop insomnia due to a fear of dying.   Heart to heart talks are free.  

Well, i hope that gives you some ideas of where to start.  It sounds like you are very caring and your Aunt is very lucky to have you.

Best Regards,
Michalene Peticca  M.A.