By Dr. Brent P. Forester, MSc., Geriatric Psychiatrist, Bridges by EPOCH at Westford
Imagine the following scenario: Your mother has Alzheimer’s disease and is not only forgetful, but also easily agitated, especially in the late afternoon hours. She will pace and wander aimlessly while repetitively asking when her father will return from work. One night, she seems particularly confused and upset. You bring her to the local emergency room for an evaluation.
While in the ER, she is diagnosed with pneumonia and hospitalized for three days. During the hospital stay she is more agitated, very confused, and she sees animals and “visitors” in her bedroom that are a product of her confused imagination. She becomes increasingly fearful and begins yelling and pulling out her intravenous line. The doctor orders medications to calm her and she is sent to a nursing home for rehabilitation.
While at rehab she is weak, has trouble standing and is unsteady on her feet. To make things worse, she can no longer recognize you or her close family members. She is sleeping most of the day. You wonder why Mom has seemingly all of a sudden fallen off the proverbial cliff into a state of utter confusion as if her dementia has become rapidly worse over a very short period of time.
Although this situation seems frightening and complicated to understand, the scenario you just read is actually quite common and involves the interaction of medical problems and medication side effects in someone whose brain is already compromised by dementia. For an individual with dementia, the onset of medical problems such as pneumonia, a urinary tract infection or poorly controlled diabetes can rapidly lead to worsening confusion and agitation.
As a general rule, dementia does not progress overnight. Such a rapid worsening of both behavioral and cognitive problems signals a medical problem or medication adverse effect that must be carefully and correctly assessed, diagnosed and then treated.
Your Mom, in the case just described, had increasing confusion and agitation at home due to the onset of pneumonia. While hospitalized in an unfamiliar environment, she was given medications, such as anti-anxiety or antipsychotic medications, that calmed her down, but over a few days created a condition of unstable gait, worsening confusion and sedation.
In other words, in an attempt to help calm her down with medications, she all of a sudden seemed more demented when actually her worsening gait, sedation and escalating confusion was a complication, most likely, of a highly dosed, ill-advised medication, such as haloperidol or lorazepam – two medications commonly and mistakenly given in acute situations of agitation when safety may be compromised.
A consultation with a geriatrician or geriatric psychiatrist could help in choosing medications to help calm behavioral and emotional episodes without excessive sedation or confusion. The right combination of environment, treating the underlying medical problems and judicious use of psychotropic medications can have the intended effect of calming without excessive sedation.
Balancing the need for safety and quality of life can be the most challenging aspect of treating an individual suffering from dementia. In future blog posts, I will discuss the pros and cons of different classes of medications that are commonly used to help treat the behavioral complications of dementia.
Take Home Lesson: If your loved one seems to be “falling off the cliff” in terms of worsening confusion and agitation overnight, a thorough medical assessment and psychiatric evaluation is important. These assessments will help identify the underlying factors causing the rapid cognitive and behavioral changes and recommend an effective treatment approach to restore quality of life in a timely fashion.