Down the Lithium Road

Saw him this afternoon for the first time since they started the lithium dose.  He's dramatically worse - though that may not be a bad thing.

Last time he was incoherent.  That makes it strange for me to to say that today he was much less coherent - but he was.  There were only a couple of recognizable words.  On top of that (and I think this is mainly what I'm reacting to), he's suddenly unable to focus.  When my wife and I got there, he was quiet - staring blankly into space.  Then he saw her and started talking.  He never really registered me at all.  Right away he wanted to get up from his chair - probably to show us hospitality.  He mistook another chair for his walker - grabbed the armrests and tried to push it, and got frustrated when it wouldn't roll.  I reached for his walker and moved him over to it - not easy, since he couldn't follow any of the instructions.  He was stooped over, almost at a right angle, and seemed to engage in conversation with anyone who was in his field of view, generally to his right and lower down - other seated residents, in other words.  As he moved, he'd shift conversation from one to another.  Since I was standing in front of him, he didn't pay me much attention.  After a moment or two, he froze, and just stood there, gripping the walker and muttering something to himself. 

The positive news is that when we arrived, he was peaceful.  But it became obvious pretty quickly that our visit wasn't doing him any good.  We left after five minutes or so.  I tried to tell him, as I have in the past, that we'd be back soon, but that didn't seem to get any traction so we just stepped out.

Earlier, just before we said hello to him, H, the charge nurse, pulled me aside for a discussion.  She said that twice in the past couple of days, my father has exposed himself to the other residents.  So the pattern that started with my wife seems to be continuing.  I told H about the previous incidents, and she seemed relieved that I wasn't upset.  The reason for the sidebar meeting was this: she wanted my authorization to buy him a set of jumpsuits.  He can wear them in place of his current wardrobe (mostly lounging clothes from The Gap) and they'll keep him from getting into his pants.  I said yes, of course.

Afterward, as we were leaving, I told H that he seemed to have taken a hit as a result of the lithium.  She agreed, but said that he was still hyperverbal and still aggressive.  She added that the alternative to lithium would be sedation, which they didn't want to try just yet.  I said I understood, and again she was relieved that I knew that they were trying to balance his treatment - both for his sake and for the benefit of the other residents. 

About that: long before we got him to the nursing home, and again soon after he arrived, I used to worry about whether they'd want to medicate him for their own convenience - just make him docile and more manageable.  I don't think that's what's going on here.  They do, legitimately, have a lot to juggle, and I'm sure convenience comes into it - they can't interact with him every minute of every day.  But they also have to think about the welfare of the other 20 or 30 patients on the floor, and they can't just give my father free rein to curse at them or flash them as a matter of self-expression.  And beyond all that, there's the fact that when he curses and flashes, he's not particularly happy.  So medicating him might be good for the staff, but it's probably good for the other residents, and it's also good for him.  Relieving his distress is a perfectly good use of pharma and I'm fine with it.

That said, I'm not sure about the lithium.  Frankly, I'm wondering if sedation wouldn't be the better way to go.  True, he'd be less aware.  But as I've said in the past, awareness isn't his friend.  And if that was the case a year or two ago, imagine how it is now.  So if we send him off into the fog - more quiet, more blank staring, less anger and less angst - that could be a good thing.  Which is why I said at the beginning of this post that in some respects, the worse his condition gets, the better.  Moving him farther away from consciousness would really be helpful to him now.  The hard truth is that we're parting ways with him now and he's parting ways with us and it's probably better to speed that process up, not slow it down.

I sent an e-mail to P about the visit, and we'll see what she and Dr. G want to do about the lithium, or about any meds they're thinking about.  We'll talk, and I'll go up there next week, and we'll see where we travel from there. 

Comments

[Shu]

It is so hard to find the balance with the meds and other things because the underlying condition is evershifting and degrading. It is good that he is in the thoughtful, watchful care of those full-time pros who want to help him find his way. Hard to imagine his going through this part in his apartment without this swiftly reacting care. I'm sure the staff IS relieved to find you as informed and thoughtful as you are. It's just part of the hard times of the damned disease. He does know you're there even if the neurons aren't firing in a way that let's that show. Many hugs for you all.

[Alan G. Ampolsk]

Yes, they're good. I agree with you completely about him in his apartment - in retrospect, I have no idea why I kept him there so long (it seemed a good idea at the time?). I'm fine with having them try things until they find a balance that works - or works for a while, at least.

I think you're right that he knows we're there - though if the visits keep producing this kind of distress, I'll probably have to think about slowing them down a little.

Hope the next year is kinder to you than the last one.

Best,
Alan

[Jennifer Stone]

It is such a struggle to find the right balance and type of medication and since the dementia is constantly changing it's even more of a struggle. I see so many similarities with what you are going through and my journey. My dad became severely aggressive and actually ended up in a locked ward for 3 months until they could get his medication stabilized. He was finally put on Seroquel which lasted for a little over a year. Although I know the drug is controversial for use with dementia patients (it is FDA approved for bi-polar disorder and schizophrenia), it did wonders for his aggressive behavior and I think calmed the hallucinations he was having. He did decline quickly after that, but I'm not sure if that was the dementia or the drugs. The nursing home finally took him off of it as he has declined too much it wasn't really needed or benefiting him anymore.