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Offline Anonymous

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You make the call ... Geriatric care
« on: February 18, 2006, 10:37:00 AM »
http://www.latimes.com/features/health/ ... ome-health

Turmoil in life's final chapter

Drugs can treat dementia-related behaviors. But, families know, there's a price.

By Marianne Szegedy-Maszak
Special to The Times

February 13, 2006

Perhaps the cruelest paradox of dementia both for sufferers and their caregivers is that memory loss is the least horrible of its symptoms.

It's not the grown child's name forgotten or the pill not taken or the suddenly lost sense of place that drives the elderly from homes to institutions, but the unmanageable aggression, the uncontrolled paranoia, the inappropriate sexual behavior that ultimately afflict 90% of those who suffer dementia.

"Many people get pulled out of their homes and put into institutional settings because the caregivers just can't handle all the other symptoms," says Dr. Dilip Jeste, head of geriatric psychiatry at UC San Diego medical school.

Treating these caustic symptoms is heartbreaking and complicated and has only grown more so in the past year.

Last April the U.S. Food and Drug Administration issued a public health advisory about newer drugs used to treat dementia, known as atypical antipsychotic medicines. These medicines, though approved for other conditions, caused far fewer side effects than traditional antipsychotic drugs, so patients and their families were more likely to stick with them. As a result, the drugs were widely viewed as more effective.

But, as the agency alerted caregivers and patients, the drugs can cause unexpected death in a small number of elderly people who take them to treat behavioral symptoms. The result was a "black box" warning describing the risk of using the drugs for the treatment of geriatric dementia.

In the year since these warnings were issued, healthcare providers, families and caregivers have had to weigh the risks and benefits of these medications while coping with the suffering of vulnerable patients who are unable to make decisions on their own.

Many returned to older antipsychotic medications, with their more serious side effects, such as a Parkinson's-like syndrome that makes people's faces contort.

Others, after examining the data, decided to continue with the newer medications, says Dr. Helen Lavretsky, professor of geriatric psychiatry at UCLA's Semel Institute for Neuroscience and Human Behavior.

Subsequently, a large epidemiological study, which appeared in the New England Journal of Medicine in December, found that there was very little difference in terms of mortality rates between the two classes of drugs.

"We have to remember that the risk of dying is still small," says James Ellison, clinical director of geriatric psychiatry at Harvard's McLean Hospital.

And the potential benefits of the newer drugs are huge getting out of the hospital, moving into a nursing home or assisted living facility, not being agitated or aggressive.

To help determine who is most at risk from the newer drugs' most dangerous side effects, experts say, a diagnosis may be crucial. Although many symptoms of Alzheimer's and dementia look very much alike memory loss, agitation, behavioral changes there are important differences.

Dementia is typically caused by small strokes that cut off blood flow in the brain and inevitably impair function. Over the course of a lifetime, the likelihood of suffering from the disorder increases. It affects one person in 20 over age 65 and one person in five older than 80, according to the Alzheimer's Assn.

An early study of the atypical antipsychotics established a connection between the drugs and subsequent strokes, heart attacks or pneumonia. But in trying to determine which patients were the most vulnerable to these catastrophic events, researchers found that a number of the patients in the studies had other risk factors for stroke, such as diabetes or high blood pressure.

"Can you prove that the drug caused the stroke or death with these patients?" Jeste asks. "It is really hard to prove the connection; nonetheless, you can't dismiss it."

In Alzheimer's disease, which accounts for 55% of all cases of dementia, the deterioration comes not from strokes but from the accumulation of layers of plaques in the brain that smother neuronal function. The Alzheimer's Assn. estimates that 4.5 million people have the disease today, but it anticipates that by 2050, 16 million will be affected.

Regardless of the diagnosis, or the resulting therapies, the effective treatment of such behavioral symptoms is a public health problem.

"This is a big issue," says Dr. Dan Blazer, the president of the American Assn. for Geriatric Psychiatry. "It affects an enormous number of people, and for the individuals who suffer, life is miserable."



Dueling medications

Treatment of dementia and its related behaviors is further complicated by other drugs and drug interactions.

According to a 2003 report by Families USA, a Washington, D.C.-based consumer health organization, although seniors make up only 13% of the total population, they account for about 34% of all prescriptions dispensed and 42% of all prescription drug spending.

Lavretsky says her typical patient is taking 15 prescription medications.

Conditions such as hypertension, osteoporosis, diabetes, arthritis, heart disease, perhaps cancer or mental illness, each require a formulary of sometimes two or three different drugs. Many patients also take over-the-counter medications and herbs and teas, which pose still more complications as their side effects, drug interactions or simply the way they metabolize in the liver have not been studied.

"The use of any medication in the elderly is associated with an increased risk of side effects," Lavretsky says. "The risks of each medicine have to be assessed very carefully in the context of complex management with other drugs."

Could a particular blood pressure medicine, in a particular person who is, for example, diabetic, dangerously interact with an antipsychotic? It is impossible to accurately predict each individual case, but after years of trial and error, the most judicious strategy, she says, is to use "one drug instead of many, and the lowest dose of that drug."

The drugs themselves create even more challenges for the clinician.

As in the case of the antipsychotics, some of the medications used to treat behavior have serious physical side effects. But some of the drugs used to treat physical problems can have what McLean's Ellison calls "behavioral toxicity."

For example, it is very common for older people to be on anticholinergics medications that block a neurotransmitter that is important in the brain for memory. Some of the medicines that help people sleep, even over-the-counter medications, or others that help patients cope with incontinence are anticholinergics.

An incontinent patient with dementia, who requires procholinergic medication for cognitive function and anticholinergic medication for the incontinence, presents a problem doctors encounter infrequently with other groups of patients.

"That is the problem with the aging body," Ellison says. "You solve one problem and you create another."

Simi Valley resident Lowell Dreyfus saw the truth of this observation during his father's illness.

His father suffered from Alzheimer's in the early 1990s, before atypical antipsychotics were available. At one point, his father's confusion and agitation became unmanageable for his mother, and his slow decline seemed to spin out of control.

After weeks of rages and incontinence, he tried to climb out on the balcony and jump off. His wife was able to restrain him long enough for a neighbor to call the police.

It took six officers to subdue the 80-year-old man before they took him to the emergency room in handcuffs. He was then taken to a downtown Los Angeles mental health facility, where he remained for three days and was given a large dose of the older antipsychotic medication Haldol.

Dreyfus' father reacted badly to the medication. "He was unable to wake up and completely bloated, like someone pumped him full of steroids," his son recalls. "I said to them, 'What have you done to my father? He was lucid yesterday morning, and today he is a vegetable.' "

His father eventually recovered from the episode and was given a cognitive enhancer a drug that addresses specific memory problems, not behavioral ones. He responded miraculously to it.

After another two years of relative health and even clarity, he eventually succumbed to the disease.

As terrifying as the Haldol episode was, however, Dreyfus still believes in the importance of drugs whether antipsychotics or other medications.

"Unless a person really firsthand lives with this type of disease, it is very difficult to understand," Dreyfus says. "And I believe that whatever drug is out there that can lessen the pain and make it easier for everyone to deal with the situation has to be tried."



Complicated decisions

Eventually the progression of time makes old age fatal for everyone. But researchers point out that even for the most frail and vulnerable among us, there are ways to make the final chapter of life a gentle one.

With a growing number of people living well into their 80s, and leaving spouses and children to weigh complicated choices, the question of how best to make these decisions lingers.

The possibility of antipsychotic medication was always in the back of Laurel DuBeck's mind as she confronted her father's deterioration from Alzheimer's four years ago. At 81, he had a mass of complicating conditions Parkinson's disease, diabetes, heart disease but they didn't compromise his strength or his rages when she tried to awaken him in the morning and help him out of bed.

"He would yell at me and swat at me because I was doing it 'wrong,' " recalls DuBeck, a nurse from Zanesville, Ohio. She didn't try to persuade him to change his mind, however. Rather, she distracted him with a conversation about the weather or their plans for the day, and his rages would subside. He was "unable to deal with two things at the same time," so distraction worked, she says.

DuBeck understood that the atypical antipsychotic drugs can sometimes be the only way to calm a patient, especially when the paranoia gets out of control. But the enormous quantity of medications that her father took for his other illnesses dissuaded her from adding another one. "I just didn't want to give him anything that I didn't have to," she says.

Geriatric psychiatrists agree that other health risks and realities, such as illnesses or medications, must be considered. Sometimes antipsychotics will be an option. Sometimes they won't. Regardless, Lavretsky says: "We just have to be very careful with everything that we do."


Copyright 2006 Los Angeles Times
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Offline Deborah

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« Reply #1 on: February 18, 2006, 04:25:00 PM »
Dear lord,
Skip the risks associated with drugs and
1) eliminate hydrogenated oils, trans fats and high fat meat and dairy.
2) replace 'bad' fats with 'good' fats- olive and grapeseed oil
3) increase their intake of Omegas (salmon, etc), vegetables (particularly green- kale, collards, brocolli, etc)
4) give them a glass or two of good red wine every night- which according to my mom's DO is the best 'trankelizer' to be found
5) give them CoQ10, cal/mag, fish oil, hawthorn, grapeseed extract, folic acid, and B Vits

It'll clean that cholesterol right out of their brain veins.

Everything doesn't have to be a "WAR ON". Most times it just takes some working with nature. Give your body what it needs to works right... and guess what, short of a physical abnormality, it will!!! What a fucking concept.
Eat the Standard American Diet (highly profitable for our capitalist culture) and you're gonna risk cholesterol clogged veins in your heart and brain as well as gallstones.
Oh, but they can remove the gallbladder. Yep, and then you're a prime candidate for heart disease or attack.
Work with nature. The only WAR should be against the advice of the majority of ignorant practitioners in the medical industry who haven't a fucking clue how to help people prevent disease.
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Offline Anonymous

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« Reply #2 on: February 19, 2006, 02:54:00 AM »
Quote
On 2006-02-18 13:25:00, Deborah wrote:

"

4) give them a glass or two of good red wine every night- which according to my mom's DO is the best 'trankelizer' to be found

5) give them CoQ10, cal/mag, fish oil, hawthorn, grapeseed extract, folic acid, and B Vits


This was the norm long before processed foods became dominant. Same with the trans fat, etc.

Now science is identifying Alzheimers.

Prior to that it was called hardening of the arteries.

Dementia has been a symptom of old age since biblical times.

The health food industry promises alot, and makes
it sound simple ... but are the claims every scientifically proven, or is it just a slam against western medicine and modern cooking?
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Offline Anonymous

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« Reply #3 on: February 19, 2006, 10:17:00 AM »
Sorry, this post lost
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Offline Anonymous

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« Reply #4 on: February 19, 2006, 10:58:00 AM »
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Offline Deborah

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« Reply #5 on: February 19, 2006, 11:39:00 AM »
Sorry, this post lost
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Offline Anonymous

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« Reply #6 on: February 19, 2006, 09:46:00 PM »
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Offline Anonymous

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« Reply #7 on: February 19, 2006, 10:18:00 PM »
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Offline Deborah

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« Reply #8 on: February 19, 2006, 11:01:00 PM »
Sorry, this post lost
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Offline Anonymous

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« Reply #9 on: February 20, 2006, 08:27:00 PM »
Quote
On 2006-02-18 13:25:00, Deborah wrote:

medical industry who haven't a fucking clue how to help people prevent disease."


It is puzzling to watch your posts that are so angry at the pharmaceuticals and physicians.

Then you quote a book written by two doctors ...?

Who just give out menu's and state in a different kind of presentation what the American Heart Association has been teaching for many years.

When in most cases it comes down to people making their own choices. When they don't make the choices that agree with you, down comes your wrath.

Why are you so angry?

BTW - That darn life expectancy just keeps going up, and up, and up! Hate when that happens to torpedo those anti free choice activists.
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Offline Deborah

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« Reply #10 on: February 20, 2006, 11:54:00 PM »
These two doctors are exceptions to the rule, and challenge the main stream treatment model. Had I not read their book, my mother would have stints, if she survived the highly risky procedure, and be taking drugs that could have equally damaging effects.

I visited the AHA website and didn?t find anything about ?reversing? heart disease. While they make some good general recommendations (may have even adopted some from the Framingham study), the information is not specific enough to accomplish that. Now, if I missed the section on reversing heart disease, let me know.

What I found most useful to come out of the study was how to assess your risk. Get a full panel done. Divide the LDL (bad) by the HDL (good) and if the ratio is 4 or greater, then you should make significant changes to your diet/lifestyle.  

100/20 =  5   At risk, even with a ?low? LDL.    250/80 = 3  Not at risk, even with a ?high? LDL.

They recommend, among other things, 10g of fat per day if one is at risk.

Hydrogenated oils appear to be one of the biggest culprits. Totally unnatural and the body can?t process it so it ends up in the heart, brain, gallbladder as stones. Try to find a product in the store that doesn?t contain hydro or partially hydro oil. Good for shelf life, bad for human life.

The life expectancy thing is interesting. What is the ?quality? of life? All the studies I've read indicate the quality of life in American has decreased. We are 6th, in terms of quality of life, world wide.

My mom is 69 and can outwork me. Her twin has stints and alzheimer?s- basically incapacitated- doesn?t even travel to family events.

My wrath? Do you feel an attack on the medical/pharm industry is an attack on you personally?

It really is about choice. We all (or most of us) get to choose how we live? and die.
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Hidden Lake Academy, after operating 12 years unlicensed will now be monitored by the state. Access information on the Federal Class Action lawsuit against HLA here: http://www.fornits.com/wwf/viewtopic.php?t=17700

Offline Anonymous

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« Reply #11 on: February 21, 2006, 12:13:00 PM »
Quote
On 2006-02-20 20:54:00, Deborah wrote:


My wrath? Do you feel an attack on the medical/pharm industry is an attack on you personally?



It really is about choice. We all (or most of us) get to choose how we live? and die.



"


Thanks for the detailed answer.

Regarding does an attack on the medical, pharmaceutical industry affect me personally?

No.

I went through my "absolute" angst against the AMA, Psych Meds, and through all my energy to alternative choices.

What I found out the hard way was that 1/3 of all medical expenditures are cash for the alternative methods.

The amount of criticism the alternative practicioners, health food employees, and advocates had against western medicine was so consistant, and similiar, that as I deteriorated I had the chance to step back and look at my past decade.

At the same time I got involved in mental health advocacy. I observed that the alternative dogma was extremely negative, consistantly smashmouth that a vulnerable patient would often be afraid of western medicine, and then feel guilty that they where not doing well with alternative methodes. As they where going further and further downhill.

Then I noticed that the big bad western medicine was not practicing smashmout against alternative medicine.

To do poorly for the mentally ill usually means disasterous outcomes in their personal lives. With the reinstitutionalization of the mentally ill into jails, it was imperative that a patients free choice be accompanied by unbiased information.

I was involve, what more can I say.

Manipulation is horrible to a sick, vulnerable person. Asking for unbiased information should not produce an argument. Just the facts, sources and citations.

That is not what happens. Check out your posts, and the consistancy of your smashmouth towards anyone who disagrees with your dogma.

Then re-read it, and the disagreements are not that at all. Just ordinary people either practicing their free will and choices and try to tell you that your smashmouth doesn't apply to them. And you respond harshly.

Why would those that you chased off of Fornits have such bad posts against you? Because you offend them.

Anyway, my quest for unbiased information for any health problem is not against you, it is the higher ground, seeking to find the unbiased in biased statements and providing the other side, if necessary, so that the reader can make an decision for themselves, with no verbal coercion.

If you, and others, could change your wording ever so slightly then you would have policy statements that an individual could follow, if they choose.

If the attacks on any type of practice, other than your choice, continues then it is not unbiased and those that are informed know that you are not experienced but rather spewing out items that you can cut and paste.

When this happens and you are critical of another form of treatment then a person might buy into your dogma not because of the treatment but rather to be against something.

Being against pharma, or physicians, is myopic.

Just like being agains anything alternative is myopic.

Having the ability to read what is available regarding any illness and to make one's decision is what it is all about.

Yes, people should have the right to choose however they want to live.

You are practicing this right, yes?
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Offline Anonymous

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« Reply #12 on: February 21, 2006, 12:46:00 PM »
> My mom is 69 and can outwork me.
> Her twin has stints and alzheimer?s -
> basically incapacitated- doesn?t
> even travel to family events.

When growing up was your mothers twin
sister always the sicker, more frail
of the two?
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Offline Anonymous

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« Reply #13 on: February 21, 2006, 12:51:00 PM »
> The life expectancy thing is interesting.
> What is the ?quality? of life? All the
> studies I've read indicate the quality
> of life in American has decreased. We
> are 6th, in terms of quality of life,
> world wide.

Yes, quality of life is key!

Could you post the links to these studies?
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Offline SHH

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« Reply #14 on: February 21, 2006, 01:00:00 PM »
I personally feel that if at all possible it is better to keep the elderly family members at home and with people they know. I think that keeps the mind active and they feel safer. I take care of my 102 yr old grandfather. Up until just last year, he was very active, very coherent, and didn't have any significant health problems. But after a bout of Pneumonia in December, he became confused and hallucinated and became upset and agitated and paranoid. After 2 weeks in the hospital and many tests, they determined no particular cause other than lowered circulation in the brain. They put him on Seroquel, which, at first didnt seem to help. But the last 2 weeks have been relatively episode free. He is still 102, so every day is a bonus, but I feel that if drugs help keep the patient at home, then it should be used. He still needs assistance, and supervision, but he is at least sleeping at night and not trying to fight things that aren't there. I think a good diet helps prevent many health problems down the line in the elderly, but in my grandfather's case, at this point he should be able to eat what he wants.
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