Geriatric Medicine/Meds - 79 yr old Mom

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Hi
There is so much information that I could write but neither of us have time.  So I am going to try to write a reader’s digest condensed version of the situation.  My Mother is 79 years old.  She is still active- serves as a Foster Grandmother (a Volunteer) at the Elementary School works with Kindergarten in the am and 3rd grade after lunch.  She has been doing this for over 15 years and this year she cut back to going 4 days a week instead of 5. Sometimes she goes to church on Sunday - she lost a pastor that was dear to her and has yet to find a congregation she is comfortable with.  She also goes to Bingo on Wednesday evenings.
Mom has High Blood Pressure, which is under control with the help of these meds:
Atenolol 25 mg one in AM
Lisinopril 10 mg one in AM
Hydrochlorothiazide 12.5 mg capsule one in AM

Other meds:
Meclizine 25mg as needed for Vertigo
Fosomax 70 mg one a week (Sunday AM)
Valium 5 mg one at bedtime

She has been taking Valium 5 mg tablets every day for many years for her nerves.  She would take 1/2 tablet during the day and 1/2 tablet at bedtime. These last couple years she finds it REALLY HELPS her sleep (which has been troublesome - for her it was waking  up during the night and NOT being able to get back to sleep).  Now that she takes the 5 mg Valium at bedtime, she sleeps without waking up and is bright and sharp in the morning.
Mom has been going through some changes the last few years - very subtle at first - my husband and I have been hesitant to "label" her.  She IS getting older.  Well we went through an awful time late last November and all through December.  She was acting strange - real strange but when things were finally addressed (I am her power of attorney so - I do ask questions while I am with her at her appointments). She had stopped taking her blood pressure and recording the results- something she had done for a long time and did it on her own but she had stopped taking her blood pressure.  She DID take her blood pressure medications correctly but it somehow had gotten out of control.  Seemed like the PA at the clinic here in town (we are very, very rural) was very busy or not able to focus her attention on Mom's situation.  Please understand I am not putting this lady down because I DO like her and I DO think she has been good handling mom's health until lately.  Towards the end of last December Mom's blood pressure was 235/110.  No one seemed to be concerned about it.  She was taken via ambulance from the elementary school (there is a clinic staffed with two RN's there who assessed Mom - and once I arrived everyone talked and the decision was made to take Mom by ambulance to the regional hospital (40 miles one way).  Her blood pressure was the highest it has ever been but the problem was dizziness and vomiting.  Mom has Vertigo and takes Meclizine.  Unfortunately she forgot to take some Meclizine with her to school that day.  She was seen in the ER and was given Meclizine and a small amount of Valium.  They gave it time to work.  The ER Dr wanted to see if Mom could ambulate w/o getting dizzy if not then he would give more Meclizine - give it some time and then try to have her walk again. If this failed then he probably would be admitting her.  First walk Mom took she was just fine and so she was discharged.  I was concerned about the high blood pressure numbers and they encouraged me to speak with her PA.  I immediately called the clinic asked for an RN to call me back.  Eventually one did call - I told her what had happened and about the blood pressure. She stated Mom had an appointment in January but she felt that was too long to wait to address the issue.  A couple days later we saw Mom's PA the blood pressure was discussed and her medications were adjusted.  It did not take long - I'll say within 2 weeks of the adjustments Mom started to return to herself again.  Her blood pressure has been under control.  She takes it every day - I see that she is recording her results in her daily log..  
Ok Blood Pressure is under control.  Mom is having "issues" and is going through some changes.  Yes sometimes she has personality changes too.  Back in November she had an MRI but for some reason they could not give her the dye that the PA would have liked to seen on the test.  She had ultrasounds she also had an ultrasound on her carotid arteries to see if the 40% blockage had increased but she was the same.  The PA could not say with confidence that Mom did or did not have some type of early dementia.  She wanted to give it some time and then if things stayed the same or got worse she wanted to send us to UM Hospital to be seen by a Neuropsychologist.  UM Hospital is about a 6 hour drive - not sure how Mom would react to having to making that trip.  Personally I have seen names of Geriatric Doctors in the same town where our Regional Hospital is.  I wonder if they could give us some type of diagnosis.  

We saw Mom's PA on May 8th - took in her blood pressure log.  I did not have much to say I just was quiet and listened.  The PA did not give her any type of testing  (like the mini test that can be done to see if there is a dementia starting-  Mom has done this before and passed it with flying colors.  Math problems backwards in her head, what day, date , year it is.  Who is the president ... so on etc).  At the May 8th appointment the PA decided to start Mom on Aricept 5 mg daily for memory problems (explaining to Mom that there is no cure but this will slow things down - she said Dementia not Alzheimer’s).  This seemed like it would be OK.  5 mg is not supposed to be a very large dose.  She stated that they would increase the dose overtime.

I had to go out of town to my doctor for a physical required by my husband’s employer’s insurance company (he and I went the same day) had to be done by May 31.  I was wondering if I should delay starting the Aricept until I could return from my trip.  I called the clinic did not receive a call back - it was getting close to quitting time on a Friday so I called again.  I was put through to a nurse and it sounded like they were really busy.  So I asked my question - they wanted her to start taking it when I returned.  THEN I asked another question.  The Aricept literature stated to take it at bedtime.  That it could disturb her sleep.  I thought it might be ok as that is when she takes her Valium TO GO TO SLEEP. I was told point blank in a very rude way that the Valium HAD TO BE STOPPED (even though we had just been at the office and the nurse did the usual intake asked about her meds – same as it has been 5 mg of Valium at bedtime. The PA had to overlook this information when she prescribed the Aricept).  The actual statement that I was told was DROP THE VALIUM.  I was thinking to myself - hmmm does this nurse realize EXACTLY WHAT SHE IS ASKING? She can't possibly think that after several years of taking Valium every day that a 79 year old woman is going to go COLD TURKEY off Valium.  I was a bit stunned and said you have to be kidding me - you want her to go cold turkey off valium - no attempt to taper her off or anything like that.  The nurse said well the PA just walked by and I asked her and she said DROP THE VALIUM.  Understand my mother is NOT an Addict never has been to ANY type of drugs- she doesn't like alcohol.  She does not have an addictive personality.

So my husband and I talked about this and for now the Valium stays as is and the Aricept is not being started because I am concerned about stopping Mom off the Valium without some type of tapering or other method of coming off  Valium.  
I could be dead wrong ... but I know that Valium is in the Benzodiazepine Family.  This Family usually is used for the short term only - in most cases.   But she has been taking it for many years - long before her PA came to town.  She has never taken more than 5 mg a day with the exception of March, April and May of 2006 when my older brother - her only son - died after a horrifying fight with MS.  He had it very badly - ended up not able to move anything from the neck down.  He had terrible bedsores.  I took care of him the month of April at his apartment through Hospice.  But understand this was EXTREMELY HARD on Mom.  Her only Son.  She and Dad had been divorced for some time and she had no interest in getting married again.  So she had my Brother and then four years later I was born.  Now she has ONE child left.  I believe she probably used a bit more Valium during those early days of losing him.  But that was 2006 and it is now 2014.  She has been taking one Valium 5 mg daily consistently for years now.

I would like to know about taking someone my mother's age with many years of taking Valium (with NO increase of dose)- taking her off without some type of tapering of the medication.  I don't know if there are meds that can help with this or not.  I have been told Buspar would be not be much help when working to stop taking a Benzodiazepine after being on one for a long time.

I am concerned – I do have some background with Benzodiazepines, 3 classes of Antidepressants along with other meds that work together to help me medically manage Major Depressive Disorder, recurrent, moderate with Anxiety.  It took 9 years to find a medication combination that will work for me.  My illness has a genetic component that comes from my Father and none of it comes from my Mother.  I also will state that I AM IN NO WAY A MEDICAL PROFESSIONAL IN ANY CAPACITY.   I just know what I have had to learn over the years of fighting my illness.

Thank You for any help or information you can provide in advance.

Answer
Dear Debra:

First and foremost congratulations on your decision to devote so much time and effort to taking care of your mom. I cared for my elderly parents for the last 15 years of their lives. Dad had
Alzheimer's and numerous medical conditions, mom was very overweight with arthritis, numerous heart ailments, and ultimately cancer. I don't want to depress you but it is a long and challenging road which you've embarked upon but it will also be filled with many rewards AND most of all, the rewards will continue long past mom's presence here on earth with us. You will never regret the kindness and devotion you have dedicated to your mom. She is a very lucky woman!

I need for you to know that I am not a psychiatric nurse practitioner (though I think I could play one on t.v.) and I am answering that element of your question based upon about 3-4 months of full-time experience functioning in the psych APRN role and "flying by the seat of my pants" while working in 4 different nursing homes. Common issues with these residents were anxiety, depression, and insomnia. Whether addressed previously or not, I'd venture to say many of them had these conditions prior to their arrival at the facility. Certainly adding ANY major life event may trigger or exacerbate any or all of these conditions. Let's address the "medical" type issues first.

A BP of 235/110 had to potential to be life-threatening except that your mom appears to be in otherwise good health. If it remained at this level for any extended period of time it could have resulted in a stroke, heart damage, or kidney damage and once one of these organs starts to fail then the others seem to feel left out if they don't follow along. Fortunately you were on top of things and jumped on this in the nick of time. I'm not exaggerating when I say that you may well have saved her life. I can't say if lack of due diligence on the part of the PA contributed to this potential much larger problem but if not outwardly at least secretly she is thanking you! PAs and nurse practitioners (APRNs, NP, a few different designations but they mean the same thing; any title which has the word nurse in it - APRN stands for Advanced Practice Registered Nurse, is based upon nursing theory and total care of the patient meaning physical, psychological/emotional/spiritual, and social. We've practiced this for years as registered nurses and you just can't forget it once you reach the advanced practice level. PAs on the other hand function on a medical model. Under the direction of the physician, they are looking at the body as a bunch of inter-related organs. They seek to find and treat medical conditions with medications focusing less on what other issues may be contributing to the situation i.e. major life changes such as retirement, loss of spouse, fewer friends and family members with age, and as a result an increase in isolation and loneliness. Fortunately, your mom seems very active for her age and continuing these activities to the degree and for as long as possible will reward her nicely.

BP: Her medications are pretty standard. Atenolol is not used as much these days but it is inexpensive and still does the job. Depending upon how much of an issue or how mom feels about taking this number of pills, I believe that lisinopril and possibly the hydrochlorothiazide (HCTZ) can be combined to eliminate one more medication to remember to take. I am assuming that your mom's dizziness and the fact that it is being treated with meclizine means that she had a workup for vertigo and it was determined NOT to be caused by narrowing of the carotid arteries in the neck (such that they are less than 70% blocked), she doesn't have a "pinched nerve" in her neck, and her electrocardiogram (EKG) which seeks to find a problematic heart rhythm are all normal. In actuality, the EKG is just a "test at a given point in time" meaning that if mom had an irregular heart rhythm which occurred only intermittently it could happen again within 5 minutes after having a PERFECT cardiogram. As such, a Holter monitor is usually applied on an outpatient basis and the patient wears this small device for a period of 30 days and keeps a journal of any periods of heart fluttering, dizziness, or other concerning symptoms. At the end of the 30 days the rhythm strips are reviewed along with the journal to determine if when certain symptoms are reported something different than the normal heart rhythm is appearing on the EKG strips. Unfortunately, though better at capturing an irregular heart rhythm than the EKG, this method too is limited by the 30 days during which it is worn. Mom could be fine for 30 days and on day 31 feel dizzy again. Additional testing should have been done including a "tilt table" and possibly a stress test and there are other cardiac tests which may also have been done at this time. In the event that this workup for her heart was not done, treating the dizziness in isolation as just a symptom to be "squashed" by medication would be doing mom an injustice. I'm not saying this is the case but if mom needs a pacemaker or medication to control an occasional irregular heart beat which is causing dizziness then taking Meclizine is just putting a bandaid on the problem. Additionally, if any of her BP meds are contributing to the dizziness it is likely the Atenolol which is in the family referred to as beta blockers and their job in lowering BP is to lower the heart rate. If the heart rate goes TOO low due to this medication a person may feel faint, dizzy, nauseated,... or have a host of other symptoms. A slight adjustment in the medication may be all that is needed and perhaps the Meclizine could be put on the shelf.

Meclizine is a simple enough medication and it does a good job as long as it is known to be treating a specific condition. On the other hand, in the elderly much like the benzodiazepines it has potential risks too. It can cause a change in mental function as well as drowsiness and pretty extremem fatigue which can be mistakenly attributed to depression... Please research signs and symptoms or side effects attributed to this medication to see if any of them apply to your mom. It could be eye-opening what some of the side effects are for medications which some providers are quick to put the elderly on. Just a thought - it may be the best drug for the situation.

Valium: No longer a preferred drug for anxiety or sleep in the elderly as there are other drugs out there that perform the same function with less potential side effects. From my standpoint you are ABSOLUTELY CORRECT in that your mom should not stop the Valium cold turkey after having taken it for so long and not considering what is going to be used as a substitute. I know you said you live in a rural area but you may want to consider making an appointment for a one-time (more if necessary) consultation and evaluation with a GERIATRIC psychiatrist. This individual can do testing for dementia (whether Alzheimer's or not - for the most part dementia is only called Alzheimer's when another underlying cause cannot be found that has a medical basis such as hardening of the arteries (atherosclerosis) and this would be determined by testing such as the carotid ultrasounds which measure blood flow through the arteries in the neck to the brain. As you noted, restricted blood flow can also contribute to dizziness.

Dementia/Alzheimer's/Forgetfulness or change in prior mental state: For most individuals starting on Aricept should only be beneficial in the sense that the benefits usually out way any potential risks. I would strongly encourage you to take mom to a GERIATRIC psychiatrist for an evaluation (PLEASE reassure her that you are NOT taking her there because you think she's crazy but just the opposite. Problems with the brain still have some stigma attached these days and it's very unfortunate. As a result many people (sometimes those who are the greatest opponents and biggest naysayers often would benefit the most themselves!) carry out miserable lives choosing to avoid public stigma (really no one's business and the whole office staff ... is sworn to maintain confidentiality) instead of choosing to feel better and lead happier and more productive lives. I personally view psych-designated medications and counseling to be used as tools when we need them. Except for extreme cases (suicidal and homicidal thoughts), the doctor or psych APRN together determine the type of medication, appropriate dose, and the length of time that the patient will remain on the medication. If one medication doesn't work, there are a zillion others just waiting to take their place. A thorough evaluation is well worth the time, effort, and financial costs. Though people give me strange looks, I wouldn't be opposed to a couple large "dumps" of Prozac into our reservoirs once or twice a year. I think it would make the world a nicer place (I guess that's why no one has ever encouraged me to go into becoming a psychiatric APRN!)!

I'm not aware that Aricept needs to specifically be taken at bedtime. I've seen numerous patients who've taken it in the daytime. If the PA (certainly the nurse or worse the office assistant, medical assistant or receptions should not be providing their opinions) feels that there is a conflict with mom continuing to take both the Valium and the Aricept, I believe they can both be taken safely although there may be a safer substitute for the Valium, then she needs to do some research or consult with her supervising physician or a pharmacist to feel comfortable in her recommendations. On the other hand, it would be a lot easier and in my however unhumble opinion, better to just go to the highest level recommendation available to you which would be the GERIATRIC psychiatrist. Did you know that there are also geriatric physicians called GERIATRICIANS who specialize in care of the older patient. You may pay a bit more but it's worth it if you can have one as the primary care or at least a back up for consultation purposes. I'd strongly suggest that starting the Aricept and discontinuing the Valium (or substituting another medication) be done by the top dog! (no disrespect intended)

I hope I have answered your questions. In the short-term you can review mom's meds with the local pharmacist to see if he/she sees any problems with mom taking the Aricept in the daytime and Valium at night.

Best of luck to you!

Sincerely,

Gayle Gwozdz
APRN, MSN, MBA
Gerontology-C, GCM
Reiki Master/Teacher

THIS RESPONSE HAS NOT BEEN PROOFREAD FOR TYPOS due to the late time. My apologies!!! gg  :)

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Gayle Gwozdz

Expertise

My name is Gayle and I am an adult nurse practitioner (APRN)whose practice has focused on geriatrics in long term care facilities, evaluating and prescribing medications for medical and psychiatric conditions. I presently perform geriatric home assessments and physical exams in patients' homes. I can answer questions related to assisting adult children in keeping their parents at home, advising when a specialist should be consulted, advising if medications may be causing certain new problems that have arisen. Having cared for my dad with Alzheimer's for 14 years I am quite knowledgeable about what is normal and abnormal when it comes to this disease. I can help direct individuals to resources and support services that they may be unaware of. Lastly, I can make recommendations that can be brought back to the patient's doctor if he/she is willing to consider alternatives to the current treatment plan regarding a particular issue or medical problem.

Experience

I am an adult nurse practitioner with nearly 5 years experience in primary care, focusing on geriatric clients. I cared for my parents in the final 15 years of their lives interacting with healthcare providers, home nursing agencies, state agencies, Medicare and Medicaid representatives, palliative care and home hospice agencies. Prior to becoming an APRN I worked as an emergency dept. nurse for 15 years and 12 years for a large health insurance company providing medical reviews for underwriting, educating underwriters on medical conditions, utilization review and case management, requesting exceptions from medical directors to allow patients to receive medications or treatments not normally covered under their insurance plan, and I assisted in the area of reviewing complex medical claims for payment.

Organizations
CT APRN American Association of Nurse Practitioners (AANP) Sigma Theta Tau International (SITT) AARP

Publications
"Walk A Corridor in My Shoes" published in November, 2004, Nursing Spectrum.

Education/Credentials
Associate Degree in Nursing from Greater Harford Community College BSN from CCSU MSN in Nursing Management from the University of Hartford MBA from Rensselaer Polytechnic Institute MSN with Adult APRN from Quinnipiac University Graduate Certificate in Geriatric Care Management from the University of Florida Reiki Master Legal Nurse Consultant

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