Dr. Liz Geriatrics talks about medications to manage demenhttps:
dr. liz and kathy final cut
Mon, 8/8 7:46PM • 24:29
people, aricept, work, medications, dementia, doctor, agitation, pain, losing, elders, give, meds, mom, mother, anticholinergic, talked, little bit, tylenol pm, neurologist
Katherine Cocks, Mary, Dr. Liz
Hi, my name is Kathy. I've been a geriatric nurse for over 10 years. Many times when I would meet with family members of aged loved ones, they didn't always know what to do. I started this podcast knowledge for caregivers, to assist them with practical suggestions as they assist their own loved ones age with dignity and grace.
I want to welcome you back today, I am interviewing Dr. Elizabeth Lanksverk. But she goes by just Dr. Liz. She has over 20 years of experience in providing medical care to the elders. She founded elder consult geriatric medicine, a housecalls practice to address the challenging medical and behavioral issues, often facing older patients and their families. She also teaches at some major universities. She comes to us with a plethora of experience and knowledge. Before I interviewed Dr. Liz, she had to go outside because they were doing some remodeling in her office. And she ran into Mary Mary is the daughter of one of her clients. She wanted me to talk to Mary and show that how Dr. Liz was able to help her manage her behavior. So let's join the conversation. Mary is going to tell us a little bit out about her experience with Dr. Liz geriatrics and how Dr. Liz came in and helped her with her mother who has dementia. So Mary, go ahead and tell us a little bit about what was going on and how Dr. Liz was able to help you.
My mother always wanted to stay at home, my brother and I did the best that we could to make that happened. She had a lot of agitation. And it was really kind of turning into a mess. She had several falls one right after the other and wound up in a skilled nursing facility. As much as we tried to talk to them about medication for my mom for her condition. The physician who was running the facility, I don't I just don't think he had the knowledge to deal with elderly people who have dementia. So my mom was very aggressive, very agitated. And a friend of mine, Stephanie Howard, who had cared for my mother, prior to connected me to Dr. Liz. So I brought my mom here to Silverado and started working with Dr. Liz to essentially balance my mother's medications. She came here mid November of last year, and the change because of Dr. Liz's work with her and her medications. And this team here, the team at Silverado, they have a great care team. My mom is calmer, I would I would say that my mother is thriving, I'm happy, because I can see her happiness. And I see it. Just a great example is the other day I was here. And another resident was kind of talking and have this feeling rather troubled. And my mother leaned into her, patted her on the arm and talked to her a bit and really showed me great compassion. So my mom's calm. She's thriving. And I think Dr. Liz is a miracle worker. So that's my story, and I'm sticking to it.
Well, that that is awesome. Was there anything specific? Was it balancing medications or other therapeutics that really stood out to you that helped? Or was it a combination of things?
You know, I am not a doctor. So I really can't speak to the medication aspect of it. So talk to Dr. Liz. Well, if you were that like the fifth, and I didn't, I did not understand the implications of the medications. And so I was not aware of how important that was, with regard to this disease. And nor was my brother, and I don't think they were being what we were trying to use was, you know, being administered properly. But you know, there was a certain point where I started thinking, Wait a minute, my mom has severe dementia, why are we taking Aricept, which is supposed to stave it off, right and hold the disease back from you know, moving forward. So it was just really kind of a big, a big messy pile and Dr. Liz sorted it out.
Well, thank you very much. Is there anything else you want to add before I go back to Dr. Liz? No,
Dr. Liz 04:58
sorry. I just you know, I I find it sometimes difficult to explain what I do. So, I do have a TED talk and I will send you the TED talk. I mean, the the principles of my work are and I'm gonna get into the my little car studio very quickly, too, we do not do not use anti anxiety pills, you know, tranquilizers, or sleeping pills, that's like giving people shots of vodka. You know, giving them Ativan or Xanax is even worse, it's twice as powerful. And it's, you know, much shorter. So it's like the crack of the suburbs. And then people can, they can look good for a few weeks, few months, but then you become addicted to it. And the tolerance builds, and so you're more agitated, even on a dose that worked before. So they tend to up the dose and up the dose, and it just gets to be a mess. Or then if you miss some doses and go into withdrawal, you look like, you know, a raging alcoholic. So those are things that, you know, are different than is what is commonly done. The second is that we treat pain aggressively. And when I say aggressively, it's not like, you know, we use narcotics for everything, because I trained in Boston, in the 80s. And, you know, the most painful patients to take care of, or the, you know, the narcotics addicts, the heroin addicts. And so I'm very careful with that. But if you don't take care of someone's pain, they're uncomfortable and they're angry. And they're often aggressive. And often, you know, if the nurses asking for something for agitation, they'll get Ativan. Instead of like, even just Tylenol, you know, a long acting Tylenol at breakfast and dinner for someone who might have some arthritis pain is more likely to make them feel better, you know, giving them some Ativan or some Xanax to just cut down their, quote, anxiety. Now, that said, there are some elders who have horrible arthritis like bone on bone, there's no you know, cartilage left at all, or they have horrible spinal stenosis, which is an arthritis of the spine, which also has nerve pain corporated in it. And those people, you know, actually tend to do quite well like with a half of a Norco or, you know, half of a Vicodin and twice a day. And there's the, you know, there's the thought that well, you know, that only works for acute pain. And if it's long term, then it stops working. Well, it doesn't stop working with my elders. And I don't have people upping the dose because they don't know what meds they're on. And so I'd much rather take care of the pain before I give them psych meds just to sedate them. The other piece about pain is that you know, the Motrin and the Naperson, which a lot of doctors give because they don't, you know, they're not hassled by doing refills every month. And, you know, no one's going to look over their shoulder about it. Well, those are dangerous long term to elders, they increase the risk of heart attacks, strokes, kidney damage, stomach bleeds, a high blood pressure and heart failure. So Tylenol is much better choice. And then there's a few other things on our website, Dr. Lizgeriatrics.com/medications. There's a lot of information about the psychoactive medications and pain medication so that we're very good about, you know, taking care of pain. Also, the thing that is often not recognized is that common medications that we give elders like my dad was taking Tylenol PM, you know, the pm part is the Benadryl, which is an anticholinergic. And the nerve cells use choline to talk to each other. So if you have an anti cholinergic, you block nerve cell communication, you can get more agitation and confusion. And I found that if you just take those meds off, I mean, it's not like it's not anything I found. But it's it's a geriatric principle that if you get rid of the anticholinergic meds and meds, like Levitran, or Keppra, and steroids, and bladder pills, like detrital, then you're going to have less agitation. So those are, you know, the big principles. And then the last piece is if someone does have agitation from you know, and with Patsy, you know, her daughter is okay with me talking about it. Patsy did need a little anti psychotic because she was really paranoid. She thought that people were attacking her and poisoning her and she's just miserable. And we gave her just a little bit of Risperdal and it helped take that edge off. And you got to be careful with those because they have serious side effects. But they they gave her quality of life, which I think is what really counts when you get to that age.
When you were talking about the anti anxieties. Were you mainly talking about benzodiazepines versus like SSRIs. Is there a difference in your practice?
Completely, so the SSRIs are their own ball of wax, and there are some that I like to use like the sertraline, Zoloft, some mirtazapine Remeron, but they're not addictive in the way that the benzos are right? So it's okay to use them. They don't cure everything. And I've also seen situations where or the doctor says, Well, if some you know didn't work, let's give more. Well, giving too much more can either sedate someone, or things like Prozac effects or Cymbalta can make people amped up and jittery and not sleep. Again, that's in our website, on the medications page. So every one is different. And you have to kind of look at what's going on with them and look at the side effects and see what works.
When you talked about sleeping pills. What would our audience say if a doctor was prescribing that you would tell them that really question these types of pills? For older people? Would it be something like Haldol or what are the some of the other ones that they give for sleep? No,
I almost never use Haldol also Haldol is one that has serious side effects. I use that, you know, topically if someone's really aggressive, violent, paranoid and delusional and you can't control them any other way. You can use that if someone's seriously delirious in the hospital. But if you take it regularly, it builds up in the fat and it can make you look like a zombie. I like a little bit of melatonin.
Right? So sometimes you can just try the easy over the counter stuff first to see if that works.
Dr. Liz 11:11
Well, you got to be really careful because things like UNISOM that's anticholinergic all the, you know, there's a whole wall of Tylenol PM and Advil PM, you don't want to do any of that you don't want to do there's hydroxyzine or atarax you don't want to do that. So the melatonin is okay. And then I'm a huge fan of treating the pain, man. Right.
I do have a question on the on the pain. How do you kind of assess that if they can't verbalize things? I mean, does it make sense what I'm saying?
Yeah, completely. So if I have someone who's nonverbal and you try and turn them over, they hit you. I assume it's pain right. You know, it might be that they just don't want to be touched or anything anyway. But then I find giving them a little bit of medication like Gabapentin or something like that can help the sensitivity people with dementia get, you know, sensitive skin. So if you give them gabapentin, it can cut down the sensitivity in their nerves sometimes, and that'll help with nerve pain. And it works for about 80 to 85% of folks, some people get more confused, you can get edema you can get constipation, you can get sleepy. So you know there's there is no silver bullet. But you know, there are better choices. You know, I do not use Motrin and Naproxen in my elders, I like it. It helps my back pain helps with my headache, but I take it for like a day or so and I'm done. It's not okay to take every day.
So on the people, what I find sometimes is the doctor sort of started on maybe they went to a neurologist and started on my either Aricept and Namenda. And then they just never want to take them off. Because, and I've heard that that's supposed to, you know, like 18 months, but I don't know that much about it. I'm a nurse.
Yeah, the studies show that they're modestly effective, that for, you know, about 30% of the folks, they can delay entry to the nursing home for about six months. And, you know, particular patients. I've seen it be incredible, like someone who was delusional and thinking that they were being buried alive and those sorts of things, you know, that I had to use some antipsychotics, but I also use the Aricept. And then, you know, he wasn't having bad side effects. And we'll talk about the side effects in a minute. But you know, his disease progressed, and he declined. So I was like, Well, I don't think this is doing anything anymore. And I took off the Aricept. And he got really paranoid again, and delusional. So I was like, what we're putting that back. So that's a good example of when you need it. I've seen a lot of other people where the side effects can be more deadly as a hospice Medical Director, I had a number of people who, you know, we just stopped eating from the Aricept in a you can stop eating from an SSRI or an SNRI. There's a lot of things that can make you stop eating. Now. Motrin and Naproxen can do it from gastritis Fosamax can do it.. If Aricept gives you, which is also known as an episode gives you diarrhea, poor appetite, a low blood pressure, low heart rate, or makes it so you don't sleep, then it's probably not a great thing to continue and this whole myth that, oh, God, you can't stop it, because if you even stop it for a day, they'll lose all that ability that they'll never get back, which is not true. You know, it's a perfect advertising agenda, but not borne out by, you know, the evidence, and some people works. And that's great. And I use it. Other people have side effects from it, and they're miserable, and I take it off and other people just didn't do anything one way or another.
So besides, you know, that sounds like what I hear you saying is that their medication needs to be individualized for them, and it might be a little bit trial and error to as you're kind of figuring that out, when someone has a lot of behavior problems, say lashing out or it's difficult to get them cleaned and that type of stuff. Where do you suggest people go like to a geriatrician to a neurologist, you know what, what type of person can really help them with that?
You know, it depends on the community. There's some good geriatric psychiatrists, there's only 3500 Practicing geriatricians in the country. And the fellowships aren't filling. I mean, it's so sad, because, you know, it's it's complicated work. And it takes a lot of diligence. And it's much easier to be a cardiologist and do more tests and get paid a lot more, sometimes neurologists can be helpful. And other times, they're just kind of, you know, checking boxes, or, you know, I think I think a big challenge that I see, coming back to the the behaviors is even identifying that someone's got dementia, you know, that someone's behavior may have changed, they may have lost empathy, they may be acting a little bit more bizarre, or they may be more withdrawn, they may be forgetting meds for getting appointments, they may not be taking care of their finances, the way they used to be, they may not take care of their parents the way they used to be. When something like that happens, you know, you go to the doctor, and the doctor will do the mini mental status exam or the Moca, which is a 30 point test, which you know, can you do test short term memory? And can you follow directions? And can you remember three steps, and can you repeat things back. And so it does have something it is a screening, but it's only a screening, even the Moca, which is a little better, which is a little more abstract, where you have a field of numbers and letters, and then you connect, you know, the letter to the number to the letter to the number where you have to be a little bit more abstract. But you can still have a perfect score, but still have lost your executive function or your reasoning to take care of your finances or your medical affairs. And if that's not, I've got a lecture called, you know, criminals diagnose dementia faster than doctors. If that's not diagnose, you know, there's a lot of scammers out there, you know, that are going to reach your elder by phone, coming to the door, by Internet, and by mail. And, you know, even even the charities, you know, if I had one gentleman who, you know, he used to like to give, which is a good thing, but then his name got on the list. So instead of like three or four charities that he was, you know, supporting, it was like, and it was draining his bank account, and was not a concerted episode of financial abuse. But it turned out to be financial abuse, because he just couldn't because of changes in his frontal lobes. He couldn't say no to giving his money away, even though he needed right.
And I tell kids start keeping track of your parents accounts. Because my father, I knew he had dementia, because I work in the field as a nurse, and they went to the doctor, they just hadn't draw clockface, which he could do. And he could still actually manage the checkbooks about the only thing but everything else, I was like, No, this is for sure. So we had to wait, you know, get on a waiting list to get in with a neuro psychiatrist. Now, they didn't really stay to treat them once we got the diagnosis, because we're able to get a lot more help after that. But it was definitely a struggle. On my end, I was so frustrated because I was far away. And so I know you see that too of like, the screening is just a screening. And if you still feel like something is not right, I guess keep pushing for answers or keep looking for a different doctor. Well,
Dr. Liz 18:36
actually what you said, you know, do two things I find to do a quick and dirty evaluation is the clock evaluation, have them drawn analog clock with all the numbers. And then I say 10 minutes after 11 and neuropsychologist that I worked with says 1110. And if you're losing your abstract bilities you're not kind of remembering where you need to put that. And
for some reason, he could pass that way.
Dr. Liz 19:01
And that's cool. I mean, you know, it might be that he had some vascular dementia that affected you know, just parts of his memory as opposed to his reasoning area, it might have been more frontal temporal, there actually are a few people who can do pass neuropsych testing, but there's doctor and den Berg, I think from Iowa, has developed the Iowa gamblers task, where you know, if everything else looks good, but someone is risky and losing money, you do that because it tests whether they can remember a pattern of losing and then change their behavior. So it may be that everything's okay. But if you're still if they're still being very irrational with their money and they don't have that money to lose, then you need to look further.
You're right, my father did have vascular dementia.
Dr. Liz 19:47
And then the other thing that I have them do is so the other thing that I do to diagnose a quick and dirty is Yeah, so the other quick and dirty test I have is to have someone calculate 25% of $22 50 cents. I mean, if they're taking care of all their finances and their retirement money, they damn well better be able to do that. Otherwise, it's very easy for someone to come in and they can still get swindled. But you know, if they can't calculate that, then they really don't know what's going on. If you know, what you're saying is you're trying to convince someone, I find a lot of people have what's called agnosia, you know, the Rumsfeld's unknown unknowns that they think everything's okay, particularly vascular dementia. And they thrive fine, and that other people are crazy and just leave him alone. At that point, I would figure out how much money do they have to lose, you know, if what they're losing is not a big deal. I've had families kind of build walls around like intercept mail, intercept phone calls, to try and protect elders, sometimes, you know, they're sharp enough to like think, Oh, well, you're controlling me, you're trying to take control of your money and you are but you know, only for their benefit. If they go into the hospital, that's a great time to swoop in and make things change. And then you know, if worse, comes to worse, and it looks like the only way to really protect them if someone's coming in to swindle them and take over control. You know, like the sweetheart swindle like some young thing wants to come in and says, Oh, you're gonna marry me and you know, I'll take over all your funds and your house and everything. You got to get them conserved or get them a guardian, which is, you know, a knockdown drag out, but nothing else works. That's that's the last resort,
right to to get the guardianship. Unfortunately, doctored Lee Liz cut out right when I was going to have her tell us about her website and how you can get in touch with her. But first, I kind of want to summarize a little bit of what we talked about. And I know we talked about different medications. You can look those up and I will also have them in my notes to see if your parents are on those kinds of medications. I have done a podcast about benzodiazepines. Those are things like atarax, Xanax and Valium. And research is really beginning to come out about how addictive they are and how they can contribute to dementia. We also talked about other kinds of medications, anti-psychotics, and medications that affect memory, like Namenda and Aricept, which help the cells work better in the cases of dementia. We talked about pain, that first we need to address pain. So when your family members getting at the beginning of a dementia, when they can still tell you if they're hurting, make sure to find out where they have pain and what is going on. The other thing that we talk about is we manage the pain and it's okay to give somebody an opioid she said if we're monitoring it so that they can't overdose her take too much and get addicted to the opioid. We talked about the complexities that we have of people who have behavior problems when they have dementia, and that there really are not a lot of professionals out there. You can check out Dr. Liz's site. I know that she does some virtual visits to kind of give parents and family members guidance. We also talked about managing sleep and finding the right place for them and how we do that and managing anxiety and how we do that. Thank you for listening. I hope you enjoyed this interview with Dr. Liz you can find her at Dr. Liz geriatrics you can Google that if you want to you can get in touch with her. Thank you for going on this caregiving journey with me as I'm working to help family members navigate this complex process. I hope you have enjoyed this podcast. If you have found it helpful, then share it. If you wish to contact me for consulting services you can reach me at www.kathysconsulting.com Kathy's is spelled K A Thys. Remember, all content is meant for informational purposes only and