He had a brief episode of emotional stability. It didn't last. It wasn't going to. The brain damage is too profound, and the emotions just aren't going to smooth out.
The sequence was this: by the end of my last visit, he seemed calmer. The optimistic interpretation was that the Depakote and Neurontin were taking hold. Then, the following Saturday evening - the Saturday before Christmas - I got a call from one of the staff on the unit, telling me he'd fallen. No injuries - they phoned because that's part of the official reporting requirement. I found out later that he'd wandered out of his room but left his walker behind. It can happen. I guess he fell relaxed, and they got him back to his room and that was that. Once again I had the instant shock/relief reaction. His falls always used to be big events. Several of them led to ER visits. But this one was over before I even found out about it.
After that, by all accounts, he was OK for about 48 hours. Then, Tuesday, another call, this time from P, in charge of behavioral assessment. He'd had a massive rage episode. Worse than the ones during the first week? "At least as bad." Yelling and cursing at one of the residents. There'd been a staff party on the unit, with outside visitors, and she thought the noise might have set him off. They'd decided to put him on zyprexa, as needed - a Seroquel alternative, I suppose - and that smoothed him out again.
Thursday my wife and I went up there for the Christmas Eve visit. He was cheerful - very happy to see us, whoever we were. In his most lucid moment he asked my wife if she was married and asked me if I could arrange to have Alan stay over.
The conversation was mostly at a whole new pitch of incoherence. There were great arcing flights of speech cadences and word-like sounds, and for the most part I had no idea what he was trying to express. I threw random cues at him - "Wow, that's really interesting" and "they're really like that, aren't they?" - and he'd pick them up and run with them. For a couple of years, talking with him has been jazz, but now it's free jazz. A few patterns repeat. At one point he went on a more-extensive-than-usual exploration of the conceptual geography of his knee - he'd say, "You know what I found out? There's this right here..." (points just below his left knee) "...and now they come up this way..." (traces finger along leg to just above the kneecap) "...and we have to meet them here." It means something to him that I can't work out.
Then all at once he called out to Nice Befuddled Elderly Man - wanted him to come over and meet us. Nice Befuddled Elderly Man looked at him warily and sat down at a table halfway across the room, facing away. "I think I might have called him all kinds of son of a bitch," my father said, and all at once it was obvious that Nice Befuddled Elderly Man is the person he'd been yelling at. So it makes sense for him to be on his guard. It could be argued, of course, that my father's rage signifies that there's a bond between them - rage being a form of emotional connection. I looked at Nice Befuddled Elderly Man and realized that he's more closely contemporary to my father than anyone else on the unit. This could be someone he served with during the war - you could see them standing a midnight-to-four watch together, or later, working together, maybe in the late 50's starting a business together. So from a certain perspective, this is the last stand of the Greatest Generation, or whatever you want to call it (they never called themselves that). And the last stand is bound to stir up all kinds of emotions. Of course, generational connections aside, the reality is that Nice Befuddled Elderly Man thinks my father is actively dangerous, and I can see where that's a reasonable conclusion, at least when it comes to avoiding emotional abuse. Maybe it's best for the members of the Greatest Generation to keep their distance from each other.
I stepped away for a couple of minutes and had a sidebar with P and with Dr. G, a covering psychiatrist. He was in the process of upgrading the zyprexa from "as needed" to a daily dose, and writing an order for lithium. He thinks the bipolar disorder - longstanding bipolar disorder, I should add - is compounding the effects of dementia, and that managing the one might help with the other. I'm game. He liked my one-minute family psych history (bipolar grandfather rages, then there are days of silence; father copes by talking compulsively to relieve silence and dread, finally becomes a reporter, a job where you talk compulsively to draw people out; is still talking). Dr. G talked about the number of dementia patients who present with ADHD symptoms, and who turn out to have been stockbrokers and traders. We're all of us all about adaptation - something to think about, and it make geri-psych an interesting territory.
After the conversation I went to my father's room and dropped off his Christmas presents - some colorful clothing from The Gap. The idea that it was Christmas didn't register with him at all. While I was away, he tried to expose himself to my wife. He'd done this the last time she and I visited together. There doesn't seem to be anything sexual about it - it's more that he's concerned about something that from his perspective isn't working right, and he wants a visual check on the diagnosis.
With that, it was the end of the last holiday visit - holidays aren't a graspable idea for him anymore - and we went home. He wanted us to stay over in the downstairs bedroom, so we told him we'd be right back after some errands so we could do that.
A couple of minutes ago, P called. They've started him on lithium. It doesn't seem to be making him less verbal, she tells me, but it's making him less comprehensible. She said he was indefinably different somehow. When I pressed, she said that before, he was able to produce a few recognizable words. Now it's just a sea of sounds. She's concerned about over-medicating him. I agree that that's an issue, but pointed out to her that his speech wasn't much better last week, before the lithium. I appreciate the need for close monitoring - and the fact that they're willing to do it - but at this point, it's unclear what's caused by the meds, and what's caused by the ongoing collapse of brain function. She said they'd had to feed him today because he'd been caught up in his talking and he'd forgotten to eat. That's a new one, and it could be medication-related. But in all, it's part of the pattern. This year's holiday story is all about progressive collapse.
I'll try to get up there Wednesday or Thursday for a New Year's visit - or failing that, for a visit that coincidentally happens to fall around New Year's.
small note: with lithium you have to be careful about the level of it in his system -- it needs to be monitored with blood tests, so that lithium toxicity doesn't happen.
Posted by: Nancy Frank | December 27, 2009 at 05:12 PM
Thanks for that. She didn't mention blood testing, so I'll have to find out if that's part of the close monitoring. I'm not sure that the lithium experiment is going to work, and I don't think the nursing home staff is, either. But since I'm still the ultimately responsible person, I'll have to keep an eye on it.
Posted by: Alan G. Ampolsk | December 28, 2009 at 09:50 PM