AboutMargot RN BScN GNC Expertise GERONTOLOGY (NURSING ISSUES RELATED TO THE ELDERY) I have 15+ years experience working with the elderly. I would be pleased to offer any assistance I can. My areas of expertise include: Gerontology / Geriatrics, Long Term Care, Community Nursing, Palliative Care, Private Nursing Services, Intermediate / Extended Care. I also have a personal interest in Homeopathic and Eastern Medicine. If I can not answer your question I`ll do my best to direct you to an appropriate resource. Thank you.
Experience I have fifteen years experience in Gerontological Nursing both in the community, and in Long Term Care. I have worked as a General Duty Nurse, a Nurse Manager, and a Nursing Consultant in Long Term Care and Community Nursing.I have a great deal of experience working with, assessing, and educating in the field of Gerontology (Nursing the Elderly). I am familiar with the challenges associated with Dementia (Alzheimer's), Chronic and Terminal illnesses. Experience in the area 20 years of Long Term Care and Community Nursing, specialising in Geriatrics, Gerontology and PalliativeCare.
Education/Credentials Registered Nurse , Certified Gerontological Nurse, Bachelor of Science in Nursing.
Question Hello. My Grandmother, nearly 89 years old, was independent and doing well until January of this year. At that time, she had a MI, was on life support, and ultimately recovered and was discharged to a nursing home. She required PT and strengthening. She has had a change in mental status for the past 5 to 6 weeks, which is the same time the NH started Depakote QHS. They are also giving Xanax but she has been taking that PRN prior to the MI, they are just giving it routine now. She is now irritable, confused, trying to climb out of the bed/chair, and is generally pretty nasty in her demeanor. She is also constantly calling for help from Jesus and various family members for no identifiable reason. The NH staff have stated part of the disorientation is related to increased ammonia levels related to ELF @55%, thus causing liver problems. I believe things would improve if the Depakote were stopped. Having said that, what anti depressant would you recommend? Preferrably one with the minimal potential for liver damage. Please advise. Thank you.
Answer Hi Michelle and thanks for writing,
Hyperammonemia and hyperammonemic encephalopathy are common side-effect risks associated with Depakote use; it is strongly recommended to regularly measure ammonia levels (every 3months) if unexplained lethargy and vomiting or changes in mental status occur. Like any medication, the risks are always more significant and frequently more severe in paediatric and geriatric patients so we must be extra cautious when choosing medications for seniors and start with lower doses.
I would advise you ask to speak with her primary physician and first ask why exactly the Depakote was ordered. Before you talk to the doctor you should see if you can consult with a local pharmacist, or a Geriatric pharmacist I at all possible and discuss safer medications chooses and safe doses for geriatric patients. Try to be prepared and come with a list of points, eg: if she was given this for seizures then can we pls try XXX med at xxmg/day instead, if she was given this for manic-depression then can we pls try YYY med at yymg/day instead, and if she was given this for migraine headaches then can we pls try ZZZ med at zzmg/day instead, or could we even try to just discontinue it altogether?
My second question is how did they come to the conclusion she was suffering from whatever it is they felt the Depakote was necessary for? If it was ordered for confusion, agitation, delusions or psychosis, then be the squeaky wheel and make sure they have taken adequate steps to rule out the many common and treatable other cause for confusion in elderly residents. Please also note that Depakote is NOT commonly used to treat simple depression, especially in seniors.
The most common cause in older people is a Urinary Tract Infection (UTI) due to decreased fluid intake, dehydrating medications (like the Depakote she is taking) and of course the female anatomy works against us, especially if we’re incontinent. I would ask the facility RN to order a simple Urinalysis to rule this out.
Of course taking Narcotics or sedating meds like Xanax can also cause delusions, especially if your Grandmother doesn’t eat or drink much which will allow the medication to build up in her system as it’s not flushed out fast enough. Delusions can be a sign of medication toxicity which can easily be detected with a simple blood test to show serum levels; taking multiple medications can make each other accumulate in toxic levels more easily than taking each med on their own.
Those are the two of more common causes of treatable delusions in the elderly. Other very common but obviously not treatable cause of behavioural changes are CVAs (Strokes) and TIAs (Mini-strokes) which can not be detected without a CT Scan – but even if we confirm a stroke with a scan, we can’t treat them, we simply then know a probably cause of the delusions.
So my advice is to talk to the doctor about looking for treatable causes of the delusions, if her doctor won’t help (sadly, not all doctors are that interested in our elders), speak to your doctor or ask for a referral to a Gerontologist or the Geriatric Team at the local Community Health Unit.
I hope this information helps and I hope your Grandmother is better soon. Do not be afraid to be the squeaky wheel, all seniors in residential care need advocates to speak up on their behalf and ask the right questions. Do not just accept any medication the order, speak up and ask what it’s for, is it necessary and is it the safest choice and dosage? Also ask for a “Care Conference” (a meeting with all the involved healthcare professionals involved in your Grandmother’s care like her primary physician, the residence’s pharmacist, the social worker, the floor nurse, the care aide and the director of care) every six months, or sooner if concerns arise – this is your right.
