Senior Services Support Questions

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For more information on our Senior Services please visit The Division or Geriatric Medicine.
 

Obsessive Compulsive Disorder

Dad showing signs of OCD. How do we help him get the help he needs to cope with everyday matters?

Mel P. Daly MD., CMD, AGSF, Medical Director Subacute Unit replies...

Obsessive Compulsive Disorder is unlikely to occur as a newly diagnosed condition in the elderly.  It often co-exists with a depressive illness or as symptoms of dementia.  A complete evaluation is indicated.

Hip Fracture - Dementia 

My mother is 86 yrs old, has dementia and severe osteo, and, since I can remember, a  generalized anxiety disorder. She recently broke her hip after falling (she was alone at the time although she was living with my sister in Balto).  All siblings converged in Baltimore for surgery, post op and support for also for the first 4 days during rehab.  I spent nights in her room. Now that I am back in NM, in my sister's emails, she reports that  my mother was "disruptive" to all during rehab because she did not want to do it (this happened once so far) and again today.  She referred to my mother's refusal to do rehab today as "lacking motivation" and not pain or discomfort. When I was there, the rehab therapists certainly seemed to understand the ups and downs of working with dementia patients (and yes hip surgery I guess is painful and in a strange place, etc.). I never got the feedback from staff during my stay and work with her that she was at risk for not able to stay (she will likely stay as permanent skilled nursing) because she reacted to being moved to her chair, etc.  disruptive. I cannot imagine anyone interpreting her occasional resistance to the rehab in this way.  I know my sister's limitations on caretaking--she previously described my mothers behavior as purposefully "bad"--and this was before she had psych review and was medicated.  Before the fall we were discussing her next move--possibly in NM--as my sister is also I think tapped out.    Any thoughts on how to help my mom have a better rehab experience?  And would you really describe such a patient two weeks post surgery as lacking personal motivation when she cannot deal with the rehab occasionally?

Mel P. Daly MD., CMD, AGSF, Medical Director Subacute Unit replies...

Hip fracture is a major event in an older person's life, and often more so if the person has dementia.  Many factors affect recovery and rehabilitation including, but not limited to: prior level of physical and cognitive functioning, medical co-morbidities, anesthesia, type of fracture and type of repair, pain, medical complications (infection, clots , delirium, etc), fear of falling, weight bearing status, and many others.  Each person is different, but in your mother's case it really is 'early days' !  It is entirely within a recovery spectrum that your mother will have good and bad days.  Fracture healing will take at least 2 months and functional recovery will take much longer, even in the best of all possible worlds.

Every day will be different and for patients with dementia often a new learning experience every day.

It is too soon to make any major decisions about her long-term disposition.

Good luck !!

Suicidal Thoughts

I have guardianship over my mother with dementia.  I allowed my brother to have her for a visit for 4 days.  She came back suicidal, refusing to eat and drink and saying I broke her heart.  She is so depressed now, what do I do?

Mel P. Daly MD., CMD, AGSF, Medical Director Subacute Unit replies...

There has not been enough detail provided for me to provide a definitive response.  Nonetheless, if the person is verbalizing suicidal thoughts you should first remove all potentially harmful agents (guns, knives, medications, etc) from access.  She should have an evaluation by a qualified practitioner (primary care physician, geriatrician, psychiatrist, or nurse practitioner) expeditiously.

Alzheimer's Diagnosis

My 86 year old mother-in-law has been diagnosed with Alzheimer's. The most difficult symptom to manage has been anxiety. With that she wants company all the time, specifically family. The only test done was MME by her PCP. An MRI of the brain was done a yr before due to frequent falls. The Neurosurgeon ruled out any problems, but the memory and cognitive problems were not so noticeable at that time. The PCP prescribed Aricept and suggested Adult Daycare. I really wonder if more tests should have been done to rule out other causes? Could you please tell me what a Geriatrics specialist would most likely recommend in this sort of situation? Thanks

Mel P. Daly MD., CMD, AGSF, Medical Director Subacute Unit replies...

While many primary care physicians are very comfortable with the diagnosis and treatment of dementia, it may be worthwhile obtaining an evaluation by a specialist (Geriatrician, Geriatric Psychiatrist, or a designated 'memory clinic').  Our Greater Geriatrics group at GBMC does these types of evaluations if you are interested in a 'second opinion'.

Dementia/Combative Question
 
My parents 83 and 89 still live at home and have caregivers come to their house daily to provide help. Last week, a new person was sent to watch my mother while another caregiver took my father to the doctors. When the person arrived, my mother did not want to let her in the house. She had never met this caregiver before and did not trust who she said she was. My mother became combative with her and tried to strangle her. The agency wants us to have her go to a geriatric psychologist for evaluation, which we will do. I feel it is time for both parents to go to a nursing home. Because of my mother combating this caregiver, will she be refused entry into a nursing home? Thank you"

The short answer is "not necessarily." I agree that an assessment by a geriatric psychiatrist or by a geriatrician (Internist or Family Practitioner) would be helpful, to evaluate her overall medical and cognitive state, review her medications and develop or recommend a plan for maintaining her quality of life.

The triggers for agitated or violent behavior can often be subtle, and a hired caregiver who may not be familiar with how to approach a patient like your mother (for example, one who is rushed, insistent or overbearing) may quickly escalate a patient with dementia's agitation. Also, if her husband were not present, she may have been even more fearful to have a stranger show up on her doorstep insisting to be let in!

Mel P. Daly MD., CMD, AGSF, Medical Director Subacute Unit replies...

You don't describe whether your mother or father have had violent episodes before, but if this was an isolated occurrence, I don't believe a good long-term care facility which has expertise in caring for the frail elderly should hold this episode against her/you.

Finally, you mention that your parents still live in their home with hired caregivers. If they are still functional enough, another option might be an assisted living facility that specializes in the care of patients with dementia. You can learn more about these as well as nursing homes through your local city or county Department of Aging.

Thanks for your question, and good luck!


 

Elderly Ability to Travel Question
 
My mother is a resident at a comprehensive care facility. She has dementia and osteoporosis and she lost her husband last April. Her mood often is sad, and her mobility is diminishing. In hopes of lifting her spirits, my two sisters and I hope to take her to England for a week at Christmas, with her wheelchair and accessible hotel room.

My brother is very concerned about whether this trip is wise, considering my mother's declining health, and would like a doctor's opinion.

Mel P. Daly MD., CMD, AGSF, Medical Director Subacute Unit replies...

Most physicians support the idea of recreation, vacations, and travel for patients with dementia, however each decision must be individualized considering many factors.

 

Geriatrician Question
 
I am getting older and seem to be developing some issues that are not easily diagnosed could you please refer a geriatrician(s) who might want a challenge.
Thank You

Mel P. Daly MD., CMD, AGSF, Medical Director Subacute Unit replies...

When choosing a geriatrician it is useful to check that he/she is Board Certified and accepting new patients. It may be helpful to speak by phone (or in person) first to be sure that it the issues in question can likely be appropriately addressed. Listings of geriatricians are available through hospital Medical Staff offices and other sources (Office on Aging, Yellow Pages, etc).

 

Anesthetic Question
 
Could you tell me why an operation might be cancelled if you had a cough during it? Someone I know had an operation cancelled on their back because they had a cough.

Thanks

Mel P. Daly MD., CMD, AGSF, Medical Director Subacute Unit replies...

Operation was likely canceled because of possible infection.

 

Paranoia in 91yr. Old Mother Question
 
My mother is 91 yrs. old and lives alone in her own home. She is legally blind due to macular degeneration. In many ways she seems quite sharp for her age but she is experiencing extreme paranoia. She believes that her phone is tapped by a neighbor and by two other people who live a street away. She says that they knock on her house at various times every day both day and nighttime. She runs her ceiling fans constantly because she believes that they are pumping poisons into her house and she thinks this helps to get rid of the poisons. She experiences strange odors, which she believes are the poisons. She claims the odors affect her eyes and her breathing. We went out to a restaurant the other day and she claimed that they were shooting the poisons at her there and that she couldn't breathe very well. In the past she claimed people were shooting at her house and exploding bombs outside her bedroom window.

She called 911 daily and the police came out regularly. They finally referred her to social services who came out to visit her and found her to be functioning well except for the paranoia. My mother refused any help. We told her she better stop calling the police and amazingly she stopped calling them. She also believes people are constantly going past her house and that they follow her wherever she goes. Needless to say it is very difficult to be with her and reason with her at times. Amazingly in other ways she seems quite well. She remembers a great deal from the past and even the present. Her doctor gave her a quick test in the office for signs of dementia and she passed with flying colors. Her doctor put her on Aricept and she has been taking it for about 2 years or at least for part of the time.

For awhile she did not want to take it because she believed that the medication would hurt her for she said she heard about such things on the radio that they are doing to the elderly. Needless to say I am at wits end in trying to deal with her behavior. I forgot to mention that she does do all her own cleaning and some cooking and she is able to do so. Is this a sign of Alzheimer's or some type of geriatric paranoia? She has seemed to be suspicious of her neighbors for quite a long time now but not to this extent.

Any info you can give me will be much appreciated.

Mel P. Daly MD., CMD, AGSF, Medical Director Subacute Unit replies...

Delusions, paranoia, hallucinations occur in persons with Alzheimer's disease and other dementias, usually in persons who are at least moderately impaired. There are other "organic" and psychiatric causes of these symptoms. After investigating, treatment usually is with anti-psychotic medications.


 

Ringing in Ear Question
 
I have had a ringing in my ear for a couple of months. I went to my doctor and he said it could be from my blood pressure med so he took me off. I still have noise in one ear and notice I can't hear real well out of either ear. I feel I need to see an ear doctor. Do you think this is what I should do? If so can you give me a name.

Mel P. Daly MD., CMD, AGSF, Medical Director Subacute Unit replies...

Ringing in the ears (tinnitus) is a common problem that is often ignored. An estimated 50 million Americans suffer from tinnitus, and when persistent or recurrent, usually represents a loss of hearing in the affected ear. A thorough examination by your doctor and evaluation by an audiologist should be considered, and if abnormalities are discovered, referral to an otorhinolaryngologist (ENT, or ear, nose and throat specialist) may be appropriate. If the tinnitus is pulsatile in nature (often described as hearing one's pulse in the ear), a more concerning pathology may be at work, and earlier referral to a specialist (ENT, neurologist or neurosurgeon) may be appropriate.

Certain medications may cause ototoxicity, or damage to the nerves of the ear, which may or may not be reversible. In addition to prescription medications, many over-the-counter, and herbal, homeopathic, or complementary and alternative preparations may contain ingredients that could be contributing. Be sure to go over ALL medications, supplements or remedies you are taking with your doctor or pharmacist!

  

Dementia or Alzheimer's Question
 
Our family has seen progressive changes in our dad who is 76. He has problems with short term memory, has a difficult time communicating. He cannot verbally get out what he wants to say ... he gets all mixed up or doesn't know how to say it, doesn't want to drive very far anymore, he doesn't recognize familiar places, is getting nastier and more difficult as time goes by ...even accusing us of stealing from him! A recent MRI showed a minor stroke and he has cardio and cerebra vascular disease, but were told he doesn't have dementia or Alzheimer's. We think he should be evaluated by a geriatric specialist and perhaps a candidate for medication. Your opinion?

Mel P. Daly MD., CMD, AGSF, Medical Director Subacute Unit replies...

This is an excellent question.

The symptoms you describe are actually very consistent with a progressive dementing illness, like Alzheimer. Memory loss, difficulty with speech and inability to recognize familiar places or people, are common as the disease progresses. Psychiatric changes (mood changes, paranoia, etc) also may occur. You don't describe the timeline, which with Alzheimer dementia is typically progressive over years, or whether there are other physical signs that may be indicative of other types of dementing illness, but an evaluation by either a Geriatrician (if you have access to one), or a neurologist is essential. The workup typically includes a physical examination, blood work and imaging to rule out other illnesses that may mimic dementia, or exacerbate it. Thyroid disease, vitamin B12 deficiency and untreated, remote syphilis are some of the causes of dementing illness that may be reversible.

Medications may be indicated, but evaluation would clearly be the first step.

An excellent reference book for families and caregivers of person with dementia is The 36 Hour Day, by Nancy Mace,MA and Peter Rabins, MD

Aaron J Charles, MD
GBMC Greater Geriatrics Group


 

Will Sleep Apnea Patients Be OK For Surgery Question
 
I have sleep apnea and I'm planning to have rotator cuff surgery. Should I be ok?

Mel P. Daly MD., CMD, AGSF, Medical Director Subacute Unit replies...

Generally "sleep apnea" is not considered to be an absolute contraindication for general anesthesia however that may be dependent on it's severity. Anesthesiologists need to be made aware of the condition as it may influence their choice of medications to administer.


 

In-home Care Question
 
My 84 year old father has been diagnosed with cancer of the lymph nodes and is currently undergoing chemotherapy to shrink the cancerous tumor in his stomach. The results of the first treatment of chemo almost took his life. He's currently in a nursing home for rehabilitation and nursing care, with two more chemo treatments planned. We're not happy with the nursing home he's in or the care. Does Hospice provide in-home help for this type of situation?

Mel P. Daly MD., CMD, AGSF, Medical Director Subacute Unit replies...

Yes. It sounds entirely appropriate in this case.

 

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