Monday, June 28, 2010

More on Medicine and agitation and Dementia

Alzheimer's disease affects the brain. It destroys brain cells. Loosing ones memory and the ability to reason is the hallmark of Alzheimer's disease. The brain whether we like it or not also regulates emotion and behavior. Essentially our ability to feel starts with the brain. One of the hardest and scariest parts of the whole process, (besides everything else) is the behavioral changes. A person with AD, can begin to behave in very strange and uncharacteristic fashions for themselves. It is bizarre and frightening quite often for family members. As the disease wears on the person with AD looses their ability to self-reflect-to have insight into their own behavior. It is not their fault and if they could they would hate it more than you do- but they can't.
It is also unique in that one day for no apparent reason the behavior can appear quite normal and baseline and it seems everything will be okay. The next day the behavior is strange, odd, bizarre, frightening, maybe hostile, maybe threatening. It is enough to drive a family member or loved one nuts. Yet the AD victim can't help it.
Hence emerges modern medicine. "Why can't the doctor do something?" "Help them doc!"
Keep in mind to this date yours and my Federal Government and its regulating body the FDA The Food and Drug Administration has approved no medication specifically for the treatment of agitation in Alzheimer's disease. Yet in modern society we use meds all the time.
Now I don't want to get all that hate mail, thinking I am pro-meds, "pill-pusher" "doctor does not take the time" "how can they just throw meds at my mother or father, they don't even know him or her" -I know. Believe me I am not pro-meds, I just happen to know the pragmatic realities, expectations and limitations of them because that's what I was trained in. I would rather see anything and everything that can be done other than meds to help the behavior to be more balanced and normal for that person. As family members know, simple reasoning does not always work with the AD victim. -It is not their fault.
As far as the specific meds, sometimes the cholinesterase inhibitors the Aricepts of the world can help the behavior,  sometimes they can actually make it worse.
The are indicated for AD not specifically for the behavior.
Sometimes the antidepressants can help the agitation the Zolofts of the world and sometimes they can make it worse. A person with AD can be depressed, but they can't necessarily tell you. But even if you can't make a clear diagnosis of depression sometimes the antidepressants help agitation. I talked about the atypical antipsychotics in the past. the risperidones of the world. Sometimes they help, sometimes a lot, the government and medicare are all over this with warnings about increased risk of stroke in psychosis with dementia, and the omnipresent diabetes risks.
the benzodiazepines, the Ativan's of the world sometimes help, and sometimes they disinhibit and make the person worse. They are cheap, addicting-not always a worry in dementia patients, and the primary care world loves them.
Then there are the Antiepileptic meds, the Depakotes of the world. Sometimes they can help a lot in low dose, but they can also cause worsening effects with sedation for example.
It is often a balance of calming the behavior without sedating the patient too much. Sedation seems to aggravate the already declining cognition and ability to think.
Ask what your doctor is prescribing and why. If you think your loved one needs meds for agitated behavior, ask the doc which med and why.
Low and slow is the key. It is an art and a science. It takes a little finesse and knowledge base, and in medicine that like anything else is variable. The meds are not going to work miracles, and your doc is probably not stupid or holding out in the best med for some ulterior motive. They are probably adequate and average at least. But if you don't trust her or him, then get another one. If you are only allowed to see a mid-level prescriber, such as a nurse practitioner or a physician assistant, and you would rather have your loved one see someone who went to medical school and had years of residency training then ask for one.
Remember the agitation is not the AD victims fault. Think of the brain as a stoplight at a major intersection 12 lane intersection. Then a storm wipes out the power. Everyone has to get to work. There is always the asshole who runs through the intersection, and then many more who are uncertain or scared to proceed.  It is chaotic.
If you ever rented a truck, say from Penske or U-Haul they have a governor on the engine, you can't go past 65, conversely it may be tough to get up a hill. The brain is the governor of behavior. AD is the storm that wipes out the traffic light, AD removes the governor on the truck and you got a run away truck. It is not the victims fault.

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Talking about the book with the Lake Superior wind....... a calm day