Results for zyprexa dosage in elderly
Article #
Antipsychotic drugs have a long history
of being used in older adults with dementia. They've mainly been used
off-label to treat the behavioral and psychosocial symptoms of dementia, such
as wandering and aggressive behaviors. However there's quite an extensive
background history of these types of drugs increasing the risk of falls,
excess sedation, and even early death among older adults with dementia. As such, there have been a number of successful campaigns across Canada and in the
United States to reduce the use of these medications among people with dementia. so while it's important to highlight this this success, we also have to very carefully assess the type of care that takes place after people are taken off their antipsychotic drug. Living with dementia is challenging
for folks living with the condition, their families, and their
caregivers. And it might be challenging for homes to consistently implement
or use non-pharmacological therapies for dementia which might then lead to the
prioritization of other types of drug therapies. So there are two aims of this
current work: the first is to identify whether or not antipsychotic drugs are
indeed being switched with other types of drug therapies and the second aim
will be to identify if that switching is associated with other types of
downstream health outcomes such as increased risk of falls and trips to the
emergency department. We're going to use de-identified data
held at ICES to look at the records of people living in nursing homes with
dementia to examine their patterns of medication use over time. I'd first like to thank the Alzheimer
Society of Canada for awarding me this doctoral fellowship to pursue my
doctoral research at the Dalla Lana School of Public Health. And also I'd like to thank ICES for providing rich data and methodological expertise to
pursue this work. We want to make sure that nursing homes are on the right path for ensuring great quality of care for their residents with dementia.
Article #
Welcome to module 10 of the ADRC
Dementia Care Training series. This is the first of two modules
that focus on supporting people with serious mental illness
who have developed dementia. The development of this module
was made possible through support from
the ADRC of Oregon and the Older Adult Behavioral Health Initiative. This module follows 9
others in this series. The first eight modules focused
on dementia in the general adult population, and
the 9th focused on people with intellectual disabilities
and dementia. If you have not yet viewed these
previous modules you might find it helpful to do so before
viewing Module 10 or 11. Serious mental illness refers
to people 18 and older and is defined as having, at any
time during the past year, a diagnosable mental, behavior, or
emotional disorder that causes serious functional impairment
that substantially interferes with or limits one or more
major life activities. Estimates of adults living
with serious mental illness range from about 4-6%. The impact is disproportionate
to their numbers. About a quarter of adults living
in homeless shelters have a serious mental illness, and
nearly half have a serious mental illness in combination
with substance abuse. Billions of dollars
are lost every year in potential earnings. People with serious mental
illnesses have higher levels of health care costs,
including hospitalizations, and medical visits. Yet, about 30% of those with
a diagnosis of serious mental illness do not receive
mental health treatment. Although the gap in mortality
rates for those with and without serious mental
illness is shrinking, those with a diagnosis live
an average of 10-25 fewer years than
those who do not. In part, this is due
to comorbidities and higher rates of suicide. Many mental illnesses and
disorders are included under the umbrella term of
"Serious Mental Illness," including those listed here. In this module, we will focus
on Bipolar disorder complicated by delirium or dementia. Schizophrenia and dementia
is addressed in Module 11. These are two of the most
common serious mental illnesses. Misdiagnosis of comorbidities
or poorly treated symptoms cause significant distress to the
individual with the mental illness and those
who support them. These individuals are at high
risk for poor quality of life and high rates of
disability and mortality. We will tell the story of
Carlos, who is 78 and widowed. His son lives
across the country. Carlos has lived in his
apartment for 10 years. His neighbor called aging
services because Carlos has become increasingly
agitated and very restless. He is up at all hours
and seems disoriented. When asked about his son, he
wrings his hands and says that his son is going to take him
to the theater, but is late. Other times he is euphoric as
he talks about his past with the theater, all the time
pacing around the room. Is Carlos having
a manic episode, or is something else going on? You will also meet Wilma. She is 89 and lives in a skilled
care unit and is on hospice. She is quite a character,
joking with staff and beaming when they are present. She's fairly confused and often
does not know where she is, but she clearly enjoys spending time
with others and participating in bingo, her favorite activity. She has a complicated
relationship with her children. Only one of them is
involved in her care. Wilma doesn't seem like the same
person described by her family. They painted a picture of a
woman whose life was chaotic. She spent most of her time
either in bed weeping or being the life of the party,
talking incessantly, and never listening. She had no social boundaries,
telling all sorts of intimate details about her life and
the lives of her children, much to their distress. In this module, we will use the
stories of Carlos and Wilma to explore how people with Bipolar
disorders experience aging, and how providers from aging
services, behavioral health, and the health care system can
work together to figure out how to provide needed support. Throughout this module, our
guides to supporting Carlos and Wilma will be individuals with
considerable professional and personal expertise in supporting
individuals who are aging with a serious mental illness,
including those who also have dementia. We will return to Carlos
and Wilma in a moment. Bipolar disorder is a
brain illness that causes extreme mood swings. These are more intense than
the typical ups and downs that most people experience. Over time, those with a
Bipolar disorder can damage relationships with family,
friends, and colleagues. It can disrupt ability to work
or maintain normal everyday activities. People with Bipolar disorders
sometimes engage in dangerous behaviors and are at
high risk for suicide. The fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders, or
DSM-5, identifies several types of Bipolar and
related disorders. For this module, we will
highlight the two major types, Bipolar I and
Bipolar II disorders. People with Bipolar
disorder cycle between depression and mania. The DSM lists several criteria
for a manic episode, which present as an abnormally
and persistently elevated, expansive, or irritable mood. These episodes represent
a major change in behavior for the person. The criteria for a
manic episode include an inflated self-esteem
or grandiosity, a decreased
need for sleep, becoming more talkative than
usual or seeming to feel pressure to keep talking, having a flight of ideas or
feelings of racing thoughts, being distracted easily, such as
being drawn to unimportant or irrelevant
external stimuli, an increase in
goal-directed activity or psychomotor agitation,
and finally, excessive involvement in
activities that have a high potential for painful
consequences. The diagnostic criteria for both
Bipolar I and II includes a manic episode which
may precede or follow a major depressive episode. Three of the criteria for a
manic episode must be present for at least one week, nearly
every day of that week, and for most of the day. The same criteria used
to diagnose Bipolar I are used to diagnose Bipolar II. The primary difference between
the two levels has to do with the severity of mania. In Bipolar I, symptoms are more
severe and result in marked impairment in functioning or
relationships with others, or require hospitalization to
prevent harm to self or others, or there are psychotic features. A manic episode in Bipolar II
is referred to as hypomania. This episode is somewhat less
severe and does not cause marked impairment in functioning, or
require hospitalization, and there are no psychotic features. Hypomania is marked by a
noticeable change in mood and can cause
significant distress to individuals and
those around them. Bipolar II is often
paired with depression. Manic episodes may precede or
follow a depressive episode. DSM-5 criteria for a depressive
episode include depressed mood, reduced interest or pleasure, significant weight loss
or weight gain, insomnia or sleeping
excessively, restlessness or slowed behavior, fatigue or loss of energy, feelings of worthlessness
or inappropriate guilt, decreased ability to
think or concentrate, indecisiveness, and recurrent thoughts
of death or suicide, or suicide planning or attempt. To be considered a major, or
severe, depressive episode, five or more symptoms must be
present over a two-week period, and one of these symptoms
must include depressed mood or loss of interest
or pleasure in life. The symptoms must be severe
enough to be noticed and result in difficulties with daily
life, including work, social activities, school,
and with relationships. The symptoms are not due
to any other factors such as substance misuse, medications,
or medical condition. About 1 1/2% of the
general population in the United States have diagnoses
of Bipolar disorder I or II. This works out to an estimated
50,000 individuals in Oregon. You will notice that the
prevalence in the older adult population is somewhat lower,
between 1/2 and 1%, or approximately 2,000-4,000 older Oregonians. The lower prevalence among older
adults is due in part to higher mortality rates associated
with serious mental illness, and it may also be due
to under reporting. Bipolar disorder typically
appears in adolescence or in early adulthood. The average onset
is 25 years. It is an expensive disorder for
the individual, their family, and the health care system. Costs associated with Bipolar
disorder are among the highest for any serious mental illness. Most older adults with Bipolar I
or II disorder, had their first episode in young adulthood and
have aged with the disorder. Although some people do
experience a manic episode for the first time after 50 or
65 years of age, this condition is rare and is often related
to a history of mood symptoms or other
neurological conditions. Very little is known about
older adults who live with the disorder, although they do
have a shorter life expectancy of about 10 years. As they age, all older adults
experience comorbidities, but those with Bipolar disorder
have higher rates than other older adults. These include higher rates
of cardiovascular disease, respiratory disorders,
type II Diabetes, endocrine abnormalities,
and obesity. As a result of these medical
conditions, care and treatment of someone with
a Bipolar disorder becomes more complicated. This is particularly true
for medication management. Compared to younger adults with
Bipolar disease, older adults have fewer psychiatric
comorbidities. When they do occur, they are
likely to reflect higher rates of substance
abuse, which has likely been present
throughout their adulthood. Anxiety disorders are also more
common, although many older adults who do not have a Bipolar
disorder experience anxiety. Cognitive dysfunction is a core
feature of Bipolar disorder in all age groups. Up to 30% of older adults
with Bipolar disorder have significant cognitive
dysfunction. Research findings are limited
and somewhat inconsistent, but areas of dysfunction reported
most are executive functioning, verbal learning, memory,
and emotion processing. Let's return to Carlos. He has symptoms that are
consistent with symptoms associated with a manic episode. He's not sleeping, he's very talkative, and his conversation could be characterized
as a flight of ideas. His constant talk of the theater
and needing to get there may be thought of as an increase
in goal-directed activity. His neighbor does not know
whether Carlos has had a history of mental illness. Carlos also has some symptoms
consistent with dementia, including poor memory, judgment,
reasoning and changed mood. But, dementia is a slowly
progressive disease. Are Carlos' symptoms new, or
have they been progressing and are just now being noticed? I think people who work with
the elderly, what they need to understand about Bipolar
disorder is that often, patients are untreated
for their lifetime. That many people have been
diagnosed with Bipolar and manage that through use
of other drugs such as alcohol or valium or whatever, or intermittently
seek treatment, and often, don't want to
have treatment because being hypomanic--not totally manic,
but hypomanic--really makes them feel alive and more
creative and more in control than their "normal" state. So it's difficult once you
get to a certain age, just as anybody, that you want to feel like you're in
control of your life. So I think Bipolar illness, just
like any other aging person, you have to put that
in perspective, that that's an extra, additional
barrier for them. But a lot of them have coped
somewhat successfully without treatment on and off. So I think one of the things is,
as you age, things, just like any other thing, the illness
flares up, and it has to be kind of dealt with
in a different way. You just continue to have to
work with the patient to the best of your ability, to get
them to understand how it might benefit them to have treatment. NARRATOR: Understanding serious
mental illness in older adults is complicated, particularly
when behavioral changes occur. Health care, aging services,
and behavioral health service providers all have a part in
the detective work to figure out what is going on with
a particular person. Well, I think we can't be
jumping at manic episode absent some very good, clear history
that he is, in fact, a person already diagnosed
with Bipolar disorder. While the literature does
include some stuff about late-onset Bipolar or mania,
it's exceedingly rare. Carlos's case is interesting,
of course, because it's common that a worker's going to
get a referral like this from a neighbor or even
a family member, that Carlos is exhibiting
odd and strange behavior that isn't common to him. And so that's a key right there. If they say, "This is
uncommon for Carlos. Something's going on. Something's different," what provoked this
neighbor to call? How unusual is this? Or is it just kind of
like him but just worse? So questioning his neighbor--the
reporter--is very important. She probably has a lot of stuff
that she knows and can offer but isn't aware that she should
be telling us that stuff. And so she, of course,
would be the first person to really be questioning. And in a way that kind
of gets at etiology. Not just here's what he's doing
today, but what was he yesterday or last month or
even three years ago? In the case of Carlos, I'd want
to know, well, I'd want to have a medical exam done immediately
because something that comes on that suddenly does not sound
like a manic episode to me. It sounds like there
may be a medical cause. Many, many older people have
UTIs often that cause symptoms like this or symptoms
like schizophrenia when they don't really have it. So I would certainly
want to check that first. If for some reason, he had a
medical exam, and nothing came out of that, then I would want
to consult with a psychiatrist. It would be really odd
for him to have a mania at that age, that suddenly. And there could be other
medical problems going on. So I would certainly
want to check that. Well, as a member of the team
assessing Carlos, what I'd want to know are what are some
of the other underlying factors that might be associated
with what's going on? So are there medical conditions,
are there infections or painful episodes that he's experiencing,
but most particularly, emphasis on infection. Then, we would also want
to look at his medications. So what other medications is he
taking right now that might be causing some of the
issues that we're seeing. NARRATOR: It takes all of those
involved in care to answer these fundamental questions: What are the symptoms,
and what is the context in which
they are occurring? That is, what else is
happening in the environment? Finally, what are the underlying
causes of these symptoms? You will have noticed that
all of the experts emphasized the importance of
a complete medical exam and identified delirium
as a condition to rule in or out
as a first step. You may recall from Module
7 that delirium is serious. It is a medical emergency. Does Carlos have a delirium? Delirium is characterized by
disturbed consciousness, poor environmental awareness, decreased attention, changes in cognition, and perceptual
disturbances. Delirium is marked
by its sudden onset, over a period of hours or days. Symptoms often fluctuate
in a 24-hour period and are often worse at night. Fluctuations occur in
alertness, cognition, thinking, perceptions, and emotions. A person with delirium may be
hyperactive and present with agitation, restlessness,
and hallucinations. Others may be hypoactive
and be very sleepy or difficult to arouse. There may also be a
mix of these symptoms. Visual illusions,
misperceptions or hallucinations are also common. Delirium is often
reversible with treatment. However, identifying delirium
early and starting treatment immediately is critical. As described by the experts,
delirium can have many causes. The most frequent include
infections, falls resulting in head injuries, and medications,
although other conditions can be causes. Those with dementia are
at high risk for delirium. Risk also increases with
physical frailty and age-related changes such as changes in
metabolizing medications. Let's return to Ann Wheeler's
exploration of medications as a source of delirium. We would look at
anticholinergics in particular. So what is his current
anticholinergic burden? Even one anticholinergic
can cause someone to experience delirium. We would want to look at
concurrent medications. We would want to look at adverse
effects of those medications and then streamline
as much as possible. By streamlining, what I mean
is we would want to take away any medications that
aren't necessary. So if he's being treated with
an anticholinergic medication for sleep, are there other
things that we can do? So are there non-pharmacologic
alternatives to help him sleep? Rather than, let's say he's
taking diphenhydramine. So we would want to make sure
that we have good sleep hygiene, rather than using an
over-the-counter diphenhydramine product, which is
an anticholinergic. NARRATOR: Anticholinergic
medications are used frequently. They block the
neurotransmitter acetylcholine. In the peripheral nervous system
acetylcholine activates muscles. Within the central nervous
system, it acts in areas of the brain that control motivation,
arousal, and attention. Many medications have
anticholinergic properties, including those listed here. The Companion Guide for this
modules provides information about some of the
common anticholinergic medications in use. With age, anticholinergics have
many negative side effects, including delirium and increased
risk for or worsening dementia. Aging services contacted
the primary care provider who felt that Carlos needed
to be seen immediately. Carlos did not have insight
or judgment about what was happening to him. Dianne Wheeling provides advice
for working with someone in this situation. I don't really want to try to
explain in detail what I'm doing and why I'm doing that. I'm just going to redirect him
in very simple language and tell him what he can do, rather
than what he can't do. So for example,
it's not good to say, "You can't sit here,"
or "Don't do that. Don't pull on that
IV line," etc. What you want to say is, "Here, hold this," or
"Here, sit over here," or "I want to talk to you here." NARRATOR: A friend
of Carlos, with the guidance of the aging services staff
and support from Carlos' son, matter-of-factly told
Carlos to come with him and took him to
the emergency department. The medical exam revealed
that Carlos has a delirium. Carlos has been taking Valium,
a benzodiazepine, for 12 years to help him sleep. He also has a high
anticholinergic burden complicated by
increasing frailty. He has lost weight,
is less mobile, and his nutrition is marginal. All of these physical changes in
combination with normal changes in metabolism led to the
sudden onset of delirium. So one of the other things that
we would want to look for in his medication record would
be use of a benzodiazepine. It's very common for people
who are older to be on a benzodiazepine,
particularly for sleep. So we would want to make sure
that we evaluate for that. Benzodiazepines
can cause delirium. They can also lead to
cognitive impairment. So we would want to make sure
that if one of those is on board and is unnecessary at this time,
that we find a way to taper and discontinue that medication. NARRATOR: Benzodiazepines are
a class of medications that depress the central nervous
system, particularly the brain. About 5% of the adult population
fill prescriptions for benzodiazepines each year. They are frequently prescribed
for psychological disorders, especially anxiety and
panic and for mood disorders, including Bipolar disorders. They are also used
to help people sleep and for seizure disorders. Benzodiazepines have
multiple side effects and are considered high risk drugs. They are particularly
dangerous for older adults. Use is linked to higher rates
of dementia and other cognitive impairment, reduced
mobility leading to falls, and impairment in driving. It appears that long-term use
of benzodiazepines with Bipolar disorder may be associated
poorer control of symptoms compared to
alternative treatments. Benzodiazepines in combination
with other prescriptions can reduce the
effectiveness of those drugs or result in adverse
drug affects. This is also true for
combination of benzodiazepines with alcohol, over the counter
medications, and other drugs. People who have used
benzodiazepines for a long time develop a physical
dependence on the drug. Deaths due to overdoses
increased fourfold between 1996 and 2013, and continue
to rise for those over 65. Some of the commonly used
benzodiazepines are listed in the Companion Guide
for this module. I would say in terms of which
older adults would be more susceptible to the side effects
associated with benzodiazepines, that would be all elderly
patients over the age of 65 is when we want to start
using as low a dose, for a shorter period
of time, as possible. They're going to be
considered unnecessary in a lot of older adults. So we would want to look
at getting rid of them in most cases. But the other people that are
particularly vulnerable would be those that already have
an underlying dementia. And so this is
only going to make the cognitive impairment worse. NARRATOR: Carlos has been
admitted to the hospital for delirium. We now turn to ways
to support Carlos as the delirium is treated. The longer you're in a delirium,
the more opportunity you are to have adverse events: Falls,
pulling out medical devices, interfering with medical care. Also, you can have
post-traumatic stress or have trauma--psychological
or physical trauma-- from being restrained. And there are studies that
indicate you can have permanent cognitive changes if
you're in a delirious state for a long period of time. The longer you're in a delirium,
often you're not getting adequate sleep, you're not being
aware of your own needs, such as food and fluids,
and you can kind of run yourself to death,
so to speak. NARRATOR: Before we move on from
delirium as a cause for Carlos' symptoms, Glenise McKenzie
emphasizes the importance of thinking delirium first. So one of the things I actually
love about working with older adults is that this
is really complex. And while that can
be frustrating, it also can be very interesting. Part of the complexity of older
adults is that their hearts aren't working as well, their
lungs aren't working as well, they're not as good about
getting rid of infection, all these changes that have
happened over time make them really at risk for delirium. And then, delirium can look
like dementia, it can look like a Bipolar, it can look like
a bunch of other symptoms. So if you're not paying
attention, you can miss it, which we miss a lot of them
in the health care system. The doctors miss it,
the nurses miss it, the social workers miss it,
we miss it. So I think that taking the time,
again, to look at the whole picture of the person, history
of the person, history of the symptom, how long has this
been happening, is critical. Because the critical part about
delirium is that it's treatable. You need to treat whatever's
happening because it is really seen, as we say,
a medical emergency. There is something medically
wrong with this person that needs to be treated. Number ones are infections
and/or pharmacology. We're giving a new medicine,
the medicine's interacting with something, but it
is causing this person to then have that agitation and/or
have a bunch of withdrawal. But they are suffering. If you talk to someone after
they've been cleared of the delirium, they will really
talk about how fearful and how scary it is because they can
sense something's very wrong. But they can't, they need our
help, especially when they've got a dementia or any kind
of a cognitive disorder, to figure out what it is
that's causing that. So I always tell my students,
"Think delirium first. Rule out the delirium before
you go off on a, 'Oh, maybe it's late-onset Bipolar
or late-onset schizophrenia.' The most common is delirium. So figure that out first before
you go on to something else with an older adult, especially when
they already have that cognition and behavioral issues
that you can kind of like, 'Oh, well it's probably
just a bad day'." And so we really
need to focus on what's really wrong
with the person. NARRATOR: Now, suppose that
Carlos did not have a delirium and was in fact having
a manic episode. Suppose that his medical
history revealed that he did have a history of Bipolar II
and had managed it pretty well by himself most of his life. In fact, many of his
acquaintances were not aware of the condition. How can Carlos be supported? If Carlos were having a manic
episode, we would want to probably look at
what we could do with mood stabilizer medications. We would start at low doses;
we would choose medications that wouldn't interfere with
other medications or medical conditions that he has. We could look at starting
a low-dose lithium. We would want to make sure,
however, that he has good renal function, that it wouldn't lead
to further cognitive impairment. We could also consider some of
the anti-convulsive medications that are commonly used for
mood stabilization, such as a Valproate or Depakote. Again, we'd start at a lower
dose and make sure that what we're doing is reasonable
and with good outcome. If this were a manic episode and
not a delirium, first of all, the treatment--from a
pharmacological perspective-- would be very similar,
would be an anti-psychotic. But one of the things that you
would want to do is to try to build some trust with the
patient, in terms of building on their strengths. And if you can, if he's able to
redirect with you, is to really ask what helps: What has
helped you in the past? How have you managed your mania? Kind of what has
helped you in the past? A lot of times, in the acute
episode, they're not wanting to talk about that or don't feel
that they have a problem. But sometimes, they are able
to really reach back into their memory and say,
"This medicine," or "I just need to
get some sleep," or "I need to rest"
or whatever. And it's often good to align
with something that they feel is helpful that you can kind of
cling to and provide for them. So for example, I do believe
sleep is really essential, actually, for both
delirium and mania. But for mania, getting
some sleep really helps have the brain rest and heal. And so it's promoting good
sleep hygiene, providing a calm environment, clustering your
care, and if a person does finally get to sleep, to really
negotiate with the rest of the treatment team to not go in and
wake them up, and provide them a time frame for which to just
rest, knowing that they'll be safe in the environment there. So usually, a manic episode
takes quite a bit of time to abate, and hopefully, the
person is out of an emergency department and maybe into
an acute psychiatric hospitalization or getting
enough rest, being supported by others to keep
taking their medications and
getting extra rest. I think as a person becomes
more organized and less manic, is to really kind of reduce
the shame, and so really be non-judgmental about what
got them to this situation. Sometimes it's not really
anything they did or didn't do, but rather their body and
their chronic illness flaring up, just as you would
have flare ups for arthritis or other chronic illnesses. And so just slowly
letting the patient regain trust in themselves to
take care of themselves, and maybe do their own ADLs. Set up the patient to do that on
their own, and really reinforce positive self-care. NARRATOR: We now
return to Wilma. Wilma is an example of someone
who suffered from Bipolar Disorder I, and although she was
not diagnosed until her early 30s, had symptoms that
indicated Bipolar disorder in her early 20s. She had multiple
hospitalizations throughout her adult life, but had many
periods of remission when she functioned quite well. When she remained on her
medications, she did well, but said she missed the
pleasures associated with mania. What is the association between
Bipolar disorder and dementia? Evidence is mixed, but those
with Bipolar disorder appear to be at higher risk
for dementia. Combined with the cognitive
deficits associated with Bipolar disorder, it appears that those
with both conditions experience a more rapid decline than
people with dementia alone. It is interesting to note, that
continuous use of lithium, a common mood stabilizer, may
reduce the risk for dementia. Recall from previous modules
that dementia is a broad term that refers to a
group of symptoms. It is a progressive condition
that leads to deficits in memory, including impairment
in short term memory, ability to learn new things,
such as new medication or care routines, and an inability
to retrieve information. Dementia also affects a person's
ability to take care of her or himself. These deficits are seen first in
instrumental activities of daily living, or IADLs, and eventually
affect the very basic aspects of daily life. Other cognitive changes
include impairment in judgment, thinking, reasoning,
and problem-solving. Dementia can also lead
to changes in mood and/or personality. Wilma is a survivor. She was able to live
independently and maintain some social relationships throughout
most of her middle age. As with many people with a life-
long Bipolar disorder, however, her cognitive skills declined
throughout her adulthood. She was diagnosed with
dementia late in life. She was supported many years in
an assisted living community. After a series of falls and
complications from congestive heart failure, she was admitted
to a nursing home on hospice. A lifetime of Bipolar disease
is very difficult for the family and friends of those
with the disorder. In this next segment we will
hear from Marilyn, whose mother had a Bipolar I disorder
that began in her early 20s. Wilma was modeled
after Marilyn's mother. Marilyn will share what it
was like to have a parent with Bipolar disorder and her role in
caring for her mother throughout her life and through
the end of her life. So as a child, of course
I didn't know my mother was mentally ill, and she
didn't know either. In fact, people didn't
talk about mental illness. I grew up in the
'50s, early '60s. People didn't talk about mental
illness, and maybe we didn't know very much about
it at that time. But what I did know was that
my mother could be really fun. But oftentimes, when I
came home from school, I found my mother in bed. And although she was good about
taking care of us as far as having clean clothes
and having meals... I don't know what that was
like for her, but as a child, it seemed there was a lot of
chaos. Let me just say that. There was a lot of chaos
in our house as I grew up. I remember one time coming home
from school, and my mother had baked a cake. I had a little brother,
and she was in bed. I came home from school, and
he had demolished the cake. So there wasn't a
lot of supervision as we were growing up. And my mother had four children. We're three and
four years apart. So the older children--I'm the
second oldest--took care of the younger children.
So I grew up really fast. My mother's first
decomposition happened when my step-father left her. I was 10 years old. So my mother had four children
with three different men. So that sexual promiscuity
was a very real part of her Bipolar disorder. She was married to my older
sister's father, divorced him, got pregnant with me, so
I was born out of wedlock. And then she married the man
that I call my father when I was six months old and had
two children with him. They were married for 10 years. So at 10, he left her. Oh, the divorce was
less than amicable. So I mean, it was a hard
and fast decomposition. Happened over the course of
about a year, and so in that time, my father went
to court, filed for divorce. My father got temporary custody
of these two younger children, and my older sister, who was a
teenager, chose to go with him. I went to court and said I
wanted to live with my father, I mean, with my mother. And then I went to court
and said I wanted to live with my mother.
At 10. I can't believe that's
what happened, but it did. So she and I lived in a little
house on the East side of town. She had a job, a minimum
wage job working as a fry cook at the
bowling alley, which was fine with me because
I got free bowling. It wasn't all bad. But we were sharing a bed,
and she wasn't able to sleep some nights. She would just ramble on
about things that were-- It was delusional: delusional talking, conspiracies, conspiracies against
her by my father. It just happened over time. And then again, I was a child,
so I'm not sure how some of this happened, but she was committed
to the Oregon State Hospital. At that point, I just went
to live with him and his new wife and her daughter. After mom was released from
the hospital, she moved back from Medford. She never had any
visitation with us, no formal visitation at all. Her life was really hard after
that, but the good thing about my mother's mental illness was
that she responded really well to medications, very low
doses of medications. Over the years, she was on all
of them probably at one time or another: Thorazine,
Lithium, Stelazine, Zyprexa. And as long as she stayed
on them, she stayed well. But I do remember
my mother saying that she missed the highs. Forget about the days in bed,
but she missed the highs because my mother--good news also--
never self-medicated with drugs or alcohol.
She didn't need to. She would be the life of a
party because she was manic some of the time. NARRATOR: We now have a picture
of Wilma through her adult years from the perspective
of a daughter. In her 70s, Wilma moved into
an assisted living community. She was willing to move
because she had friends there. Her family was relieved because
of her increasing inability to manage her medications,
recurrence of symptoms, and increasing difficulties with
other instrumental activities of daily living. As Wilma requires more care,
what do health, social services, and long-term care staff need to
know to provide optimal support? So for Wilma, some of the things
that I would want the team to know and understand about her
care would be what medications has she been on in the past,
what has worked well for her, what medications is she on
currently, does she have anything that could be
potentially contributing to symptoms of dementia
and cognitive decline? So are there medications that we
might need to evaluate and get rid of and at least taper down
on dose, if at all possible? We would also want to evaluate
her current level of pain. Pain is going to contribute
significantly to any sort of neuropsychiatric
symptoms. So we're going to want to make
sure that that's evaluated. And make sure that her
environment is one that's going to care
for her well. Mood stabilizers, psychotropic
medications in general, can have significant impact
on medical co-morbidity. So we always look at the impact
that they can have on blood pressure, on heart rate, kidney
and liver function, and drug interactions that might occur
with the medications that are necessary in order to
treat those conditions. Most notably, lithium can have
an interaction with certain anti-hypertensives. So we would want to avoid
those and start other ones. So it's just a matter of
medication selection and making sure that there aren't
drug interactions that are going to impact her overall
medical well being. Well, the question of Wilma,
is the impact of the Bipolar disease on her current life,
but also her life throughout the life course
is important because what, as I read the case study, what
it tells me about Wilma is one, that she is lovable and has
long periods of times where she's essentially normal. And I would think that sometimes
that's even without meds, but certainly with. And there are four marriages,
suggests that she's a person that you can like and be
friends with and be with. The fact that her family has
remained involved means that, indeed, that she's had
long periods of time of seeming normalcy. And the family tries to help
when she's depressed and/or manic and get burned out. So that suggests that
probably those go on for a long time before some
intervention changes her status, such as hospitalization. NARRATOR: As Marilyn describes,
Wilma's Bipolar disorder was managed well living
in assisted living. As we know, Wilma
did have dementia. As in many families, it was
difficult for Wilma's family and caregivers to identify a
time when they first noticed. The challenges that my mother
faced with her mental illness followed her
throughout her life. The dementia, for me, would be
hard for me to pinpoint when that actually happened because
she didn't remember things, she didn't listen to me, she
had just a non-stop monologue of what was important to her. If I would try to talk to her,
she wasn't listening to what I was saying; she was thinking
about the next thing that she wanted to say. So she would just ramble on. So the cognitive decline,
it was hard to separate from her mental illness. She lived in assisted living
for five years, and so at that point, she
didn't have to remember to fill her prescriptions. She didn't have to remember to
take her prescriptions, because over the years, if I said, "Mom,
have you taken your medication?" Because I might pick up on "Oh,
you've been in bed all week," or "Oh, you're talking
really animatedly about something that happened.
Have you taken your medication?" She would just lie to me:
"Yes, I took them." But when I would go down to
Medford to look through her prescriptions before
I would bring her up to Portland to stay with
me for a couple of weeks, I'd want to make sure
she had all of her medications. And I'm looking at a bottle
that should've been refilled two weeks ago, and she still
had 10 tablets left. So she was spotty at best. So when she lived in assisted
living, her prescriptions were filled, she took her medications
on time, meals were provided, and they took good care of her. NARRATOR: The end of Wilma's
life was similar to that of many older adults living with a
chronic illness, although it was complicated by her mental
illness and its treatment. Marilyn described what happened
after the third serious fall in assisted living. They ended up admitting her and
keeping her long enough so she could be discharged
into skilled nursing. I don't know what the rules and
regulations are, but that's what happened, which was good because
assisted living was not able to care for her congestive heart
failure adequately at this time. So she was discharged on
hospice, and I wanted to move her up to Portland.
My brother was done. He said he'd taken
care of her 30 years. He couldn't do it anymore. And I really couldn't keep
driving down to Medford to care for her adequately either. And I wanted to be with
her at the end of her life. It was more important to me,
maybe, than it was to her. I'll never know, but
that's what happened. It wasn't easy to move her up
here because you had to move her from county to county,
so there's paperwork. I had to get a court order
to let me move her out of the county and became her
legal guardian at that point. I moved her into a skilled
nursing home here in Portland where she got
the very best care, and she was also in hospice. So there was that team
coming in to see her as well. And it was at that time, around those three falls, where her personality really changed. She stopped talking
all of the time. And I don't know that she was
listening, but there was more quiet time for me to engage
with my mother more and to just be at peace with my mother. So when I would go visit her,
we could play cards, or we could play bingo, or we could
just sit in the garden. We could go for walks. She was in a wheelchair
at that point. But it was easier for me
to be with my mother and to care for my mother.
So that was a blessing for me. Her quality of life those
last seven months was as good as it could get. NARRATOR: In this module, we
have explored the experience of aging with Bipolar disorders,
or with experiencing symptoms often associated with a Bipolar
disorder, and how these experiences can be
complicated by health status, cognitive decline, and a range
of age-related changes. As suggested by Glenise
McKenzie, it takes a lot of detective work to figure out
what is happening with an individual, including a
thorough medical exam, social and medical history, and
environmental assessment. In sorting out the causes of
symptoms and how to address them, it is important to keep in
mind how those symptoms impact function and quality of life. So in my experience working with
older adults who have dementia and psychiatric symptoms,
and whether that's from a psychiatric disorder, or whether
it's basically symptoms of the dementia, what I think that's
really important as we're talking about thinking about
what the behavioral issues are, and then what that means
for the person's function. So from my perspective,
regardless of what's causing the symptom or the behavior, the
importance for thinking about the quality of life for
that individual and for the caregivers is
really to think about is this impacting function? Is there something
we can do, should do? Then we start all the
assessment about what can be potentially happening
and what we can do. So that's why I really focus on
what the functional level of the person is and then how to
take care of that symptom that's impacting function. And again, I don't really care
what's causing it, from the level of improving that person's
function in the day, which then improves their quality of life. More people living with Bipolar
disease are entering old age. They are likely to have more
medical comorbidities and greater cognitive
impairment than their age peers without
a mental illness. Symptoms of manic episodes
are often confused with delirium or dementia. Aging services providers need to
be knowledgeable about symptoms of Bipolar disorder and
understand how the disorder is treated and managed. They also need to understand
how age-related change and comorbidities can complicate
care and treatment of people with Bipolar disorders. Finally, aging services
providers need not be afraid to serve older adults or
people with disabilities who also have a diagnosis
of Bipolar disorder. Help is available through
Older Adult Behavioral Health Specialists located
throughout Oregon. Contact information is in the
Companion Guide for this module. As the population they serve
ages, behavioral health providers also need to be
knowledgeable about age-related changes, including the
susceptibility of older adults to delirium, the impact on
medication management, and the need for increased supports. Mental health providers,
especially those in residential care, often
can provide ADL support to help people age in place. Aging services can help,
and resources can be found through the ADRC. In summary, aging services and
behavioral health providers need to partner with each other
and with health providers to understand the source of
symptoms and work together to obtain needed resources and
supports to enhance function and quality of life. When symptoms appear or change
significantly, always advocate for a thorough medical
evaluation to rule out medical or environmental
causes of the symptoms. Finally, it is important to
move from a system focused on eligibility to one that gives
priority to maximizing function regardless of the
source of symptoms. This concludes Module 10. Please copy this link
and complete the short feedback form. We want to know your opinions
about this module and how to improve programs
in the future. Thank you again for your
attention and your support for people with dementia
and their families!
Article #
so well led me to come to ATMC was I
had just undergone a manic episode and about I would say two months prior
to coming into ATMC I started my manic episode and I was first put into the
mental hospital where they then put me on abilify
and then after that mental hospital stay which was five for five days I went home
and I thought I had conquered that part of the manic episode but I apparently I
had not I've never been on medication for more than I don't know
just my mental hospital stay so I did taper myself off cold turkey and that
was not such a great idea so I got off the abilify immediately after I came out
of the hospital and then I went right back into another manic episode and this
time it was a lot heavier and I was in to the mental hospital again where they
then put me on even higher doses and even on even more medication which was
Thorazine and Haldol and lithium and I was on very high doses but then again I
was this is when we found orthomolecular therapy after my second stay at the
mental hospital I tapered self off cold turkey again by coming off of Haldol and
Thorazine and lithium and that again was not a good idea but it was replaced by
lithium orotate and then again I thought I had conquered that but the supplement
that I'm so excited but it would I tapered myself off too quickly and I
came back out I didn't know how to use the supplements correctly i and i again
ended up in the hospital for another for a third time and there I was put on
lithium depakote and Haldol and cogentin and I was again in the mental so I
had been in the mental hospital now that was three times prior to coming to ATMC
and I came on here I came on I was on deaf echo and Haldol and cogentin and I
had switched lithium carbonate over to lithium
so I didn't come over with that but that's what was going on in my life I
was just undergoing this manic episode and I was on and off all these different
kinds of meds and I was just kind of feeling helpless and like I needed
medication to kind of control and stave off this manic episode and that's
something that I knew I didn't want to live my life on because I've been I just
knew that's just not the way for me and I was so grateful to hear that I was
gonna come to ATMC to taper off correctly and just really undergo a
spiritual journey so my overall experience at the Detox Shoppe was one
that I will never forget I absolutely love the staff there including Katy
Lotus and Michelle like I'll never forget Katy coming in the mornings to
come get me and make sure that I was feeling all right and not for the detox
shop and just always encouraging me till I keep going in the sauna I didn't think
I was gonna get up to two hours and Katy just kept pushing me to go there and I
absolutely adore Katy and Lotus oh my gosh I cannot say enough good things so
hello it is like I connected with her so well she just she knew what to say she
knew how to keep things going in a bubbly fun manner and she just she was
so professional but so kind and so patient and just so empathetic that I've
never met a human quite like Louis before and Michelle is just such a dear
always just hanging there like providing the foot bath and just being so loving
it was just at the deep talk shop I felt very loved and very taken care of and
very blessed to be there even though at times there was moments I didn't want to
be in the sauna for two hours but it was just like you know it was nice to just
see Katy making the smoothies I was in the infrared sauna and I would just kind
of pop Katy was like my entertainment when I was sure to make the smoothies
and do the ice and she made her jobs everyone there made their jobs look so
easy I was just so grateful that I could just sit back and walk
and just detox so that's great it was an amazing experience it felt amazing to be
there and the detox shock because the energy was phenomenal but the staffs
energy was just amazing so at the Detox Shoppe shop and included the sauna for two
hours and then it included ionic foot baths and magnesium lavender baths and
when I was detoxing it was it was definitely a spiritual like detox as
well under an emotional detox because there was times where it was just like I
was I wasn't just sweating just a sweat I was sweating to get out all this
negativity and all of this fear and anxiety and anger because when I'm in
the sonnet all you can do is really like just sit there in 140 degrees and your
mind starts to race and it starts to wonder and it can easily get anxious and
it can easily get worried but there I was able to like the staff was able to
just come together and just always keep me calm always keep me happy always just
ensure that I was detoxing just getting ready for life you know I was just
detoxing everything that was making me scared and making me worried and it was
it did go beyond just sweating and I did go beyond just being in the sauna it
went on to a deeper levels we had five evening groups and they were all
extremely helpful so but the most helpful of the evening groups from me
was Dustin's seven o'clock group on Tuesdays he was amazing he just was able
to hold space in such a profound manner and this past Tuesday I actually are
yeah before leaving I was really anxious and nervous about going into another
manic episode but it was just we did this exercise and thing like what do
what is it that we want to get rid of in our lives and I did want to get rid of
the mania but it does seem needed a point like when we want to get rid of
something that there's a void and what do we want to fill that
void with and I was always afraid that whatever I feel that my manic void with
would always just continue the cycle of mania but the way he was able to
approach me and assuage my fears of getting manic again was it was
unbelievable because I was just able to be just stand there with me and just
allow me to realize that you know what it's okay to be in the moment and it's
okay to go ahead to get manic but you're gonna have more tools to deal with it
and the tools I learned at a TMC were crucial in my understanding that I'm
ready to go home and ready to like I'm prepared for this man for this man manic
episode if it should happen again as I've realized here that I've come to
realize here that I'm stronger than any manic episode in my transition back home
I feel completely supported like for that's what I was I would always talk
about being here just talked about with my care manager my therapist it was
trying to develop that plan of safety and that how can I create that a plan of
security and safety for myself and I feel so blessed to have been able to
come here and develop that security net because absolutely I have a family that
loves me I have as the staff here immediately embraced me and I always
felt supported here and I know most people aren't able to experience that
because they're they feel alone in their plight and I was so blessed to just be
cared for and loved and be supported so yes I completely feel support like
support in my transition home and in my transition here the tools that I learned
here were to like had a lot to do with self love and self regulation and it was
just like coming back to a Center and being in the and being very mindful and
being very trusting of like that I'm going to be able to I know myself well
enough to identify the the symptoms of the manic episode and it
was just a matter of being able to communicate that with my support system
such as my family and especially my mom and my dad and what I've been taught
here is that it's okay to ask for help and to reach out and to advocate for
yourself and I've learned that not everything's going to be perfect and not
everything's gonna be solved overnight in a manic episode isn't going to be
solved by just isn't going to be solved overnight it's gonna take time and it's
gonna feel like it's gonna never go away but what I've learned here is that by
living in the present moment and by acknowledging what it is that you're
going through that you will be able to get past even your darkest moment I
absolutely loved everything about my stay at ATMC I love seeing the
housekeeper's in the morning they always had such a cheerful and bright demeanor
and I loved the my bed it was always made for me that was amazing I loved the
grounds that the ground I would always see the groundskeeper maintaining the
pool maintaining the the garden and it was just such an idyllic setting that
there was nothing really here that I can beat that created anxiety and that
created worry however it was quite interesting to me to see that people
here still had that anxiety and still had that worry and I still had my fears
but what ATMC does such a great job of doing is I'm meeting people where they
were at and I enjoyed that I was able to always reach out for help when I needed
to and I was able to always take here was a day where every day was a mental
health day you were able to just meet yourself where you were at and do
whatever it is that you needed to do to respect yourself and center yourself and
relax yourself so there's not I absolutely loved it there was no one
particular thing that I can say that really what I loved more that I loved
more than another it was just the fact that I was able to do whatever it is I
needed to do to heal myself in this an ATMC created an amazing environment and
cultivated an amazing environment to do that if you're considering ATMC do not
even consider just come here like you just it's a must if you're able to it is
probably the best thing you could do for yourself it honestly the message that I
would like to just say it's just keep keep the faith while I was here like
there was moments where it always felt like I was in the right place but it was
it got difficult at times to the point where I wasn't happy with certain things
about myself I was just like I don't think I can do this I was losing faith
in myself and I was not sure if I could go on like this because there was this
journey was the more of a spiritual Odyssey and it's something that no one
should take lightly but it's honestly one of the best experiences I've ever
had and you shouldn't consider anything else other than a TMC if you're trying
to get off your medication if you're trying to just get get yourself
rebalance this is the place where you cultivate mindfulness cultivate self
compassion and love and you just really learn to find yourself here and I really
believed that a TMC would help a lot of people with their goals