What is the cure for dementia, high cholesterol and macular degeneration in both eyes while on remeron and synthroid?
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My elderly mother who lives in an Assisted Living facility is on the medication Remeron 7.5 mg for Depression and as an appetite stimulant; prior to falling 11/5/13 she was only on Synthroid, supplements and Albuterol twice a day for bronchial COPD; it was found out that she had adult failure to thrive, dehydration with sodium a bit lower and her breathing issues were acting up at the time of the fall also; she went to a rehab / skilled nursing facility for almost two months, had been put on Megace for appetite stimulation yet that has side effects of DVTs which she is prone to, so the rehab facility decided on Remeron, low dose; my mother does have some mild dementia and this was the 4th visit to the hospital and rehab in 1 year; with each incident her mental issues worsen somewhat and her short term memory is very bad and she has confusion which I did not know is a result of the Remeron or maybe it is just her demential worsening; with each hospital visit it either revolved around a breathing incident (aspirating) which in past she almost died twice in the hospital, and has kyphosis of the back with a small hiatal hernia so with all the breathing incidents her lung capacity is less; yet with rehab her O2 levels are in the 90s yet wears oxygen at night due to O2 dropping below 88 for a bit; does not qualify for daytime oxygen per Medicare guidelines yet I know if she is just sitting around levels will drop; problem is that my 88 year old mother still does not qualify for nursing home yet she is walking a fine line and I worry about the medication; she did not do well on Exelon patch this past Spring as she had bad side effects; Celexa back in 2011 after a AAA surgery end of 2010 also cause sodium imbalance and she got very confused and fell and broke her hip; then she doesn't do well with pain medicines due to esophageal issues and has a bad lower back too due to an injury; it is like we are going in circles and she just returned to assisted living yet they don't watch them as well as in a nursing home environment yet she still does not qualify because she can still do certain things independently, even with severe macular degeneration in both eyes; the Remeron has helped her mood and her appetitie; I fear their is confusion with it and she has high risk of UTIs too over the three years yet it does not seem to be one of the major side effects and I wonder if it is just her dementia escalating with all the trauma of falls and breathing incidents and then moving from hospital to rehab and then back to Assisted Living I just like to know your opinion as she has a doctor at the facility yet I'm not super thrilled with his evaluations in past and I prefer the nurse practitioners; they only each come maybe 1/2 day a week as there is an LPN nurse there Mon-Fri 8-5; the caregivers are not CNAs and neither are the med-techs medical people; it is like mother is caught up in this in between world and I'm trying to figure out the best medicaiton and best thing do to for her as her only daughter by her and POA and it is very difficult to know to do the right thing; it is always about risk vs. benefit too and the more care she gets the more care points they charge with more money out of pocket from her as she is private pay; Medicaid beds are hard to get in this area too and even though she has bounced back many times in 3 years things are really geting tricky of late. She can pay right now yet with all the care money is going to go fast and she also could have really declined if the doctor(s) in the hospital had not put her on something to get her appetite going; plus I'm told with advancing bronchial COPD the patients sometimes can get depressed or lose appetite; well it is between breathing and eating! Anyway, in addition to adding Remeron her Pulmonary practitioner recently added Spiriva and Advair in addition to twice a day Albuterol. Just don't know what is best anymore and I think time is going to play everything out yet it was just 4 months after her last hospital visit she fell again and uses a walker as she insists yet doesn't seem as strong as prior to this fall; she will get rehab starting up again this week yet...I'm stil concerned about side effects yet medications seem to be what keeps her going as I know it does with a lot of elderly; in fact hoping to get her on something for the dementia too yet that will also be a great task and assisted living facilities don't pay attention to side effects too much; plus I have my own share of health problems and trying to keep stress down and once I get healthier want to return to work; elder care certainly is not easy! Thank you very much!
Posted Fri, 24 Jan 2014 in Medicines and Side Effects
Answered by Dr. Saumya Mittal -13 hours later
Brief Answer: Sympathies. Need few details. Few Investigations Detailed Answer: Hi, welcome to our site. Read your query, and I think that this is a very significant question. And I appreciate your problem. I will try my best to answer your query. First and foremost, my sympathies towards your mother. The care of the elderly is indeed a difficult task and very taxing on the care givers also. You definitely seem to be stressed out, as I can make out from your query. From what I understand in your query, your mother has a very bad combination of dementia, COPD, hyponatremia. All of them are significant causes of fall, and each of them contributes to the next condition. Dyslipidemia, or high cholesterol, does not contribute in any way. She is on medicines for hypothyroidism, and I hope that the thyroid levels are well corrected. Because if they are not corrected, the patient will have dementia, weakness and depression. And with the other associated conditions, it is not really going to help. A common feature observed in the elderly is that the fall because the develop vertigo when they rise. This is usually due to fall in the blood pressure that happens in everyone, but becomes more significant in the elderly. In everyone else, the other compensatory mechanisms prevent this fall of blood pressure. I therefore suggest that you ask her to wiggle her toes for a few minutes before she rises, and walk nearer to walls so that she can try the support of the wall if she feels like she is going to fall. The patient has had problem with her falls and has even had aspiration. These are all age related problems and become more prominent with associated conditions your mother has. I agree with the medicines that your pulmonologist has added for your mother. However you have not mentioned the dose and the frequency of these medicines. Another thing you need to know is that in the patients of COPD, the normal saturation of oxygen should be maintained between 88 and 93 %. So talk to your pulmonologist if she really needs too much oxygen. Oxygen may have been added for other reasons, which may have been omitted in the query. I suggest she should be subjected to an Arterial blood gas. Accordingly your pulmonologist may be able to suggest if she does need a BiPAP machine for support. I can suggest that you have the thyroid profiles checked, along with an ABG, to rule out hypoxia and hypercarbia. I think getting an MRI of the brain would be a good idea to rule out and/or to find out the extent of stroke. I would also suggest you meet a physician dealing with geriatric patients once. This would be helpful cause he can offer you solutions for minor problems that the patients usually face. I failed to understand what AAA surgery stands for. I hope this helps you. Inform the reports mentioned above so I can be of help further. Best of luck. I have tried and given you the answer to the maximum considering the information provided. The results of the tests could further enhance my answer to you. Please do understand that some details could be extracted from a detailed history and examination only. (If the answer has helped you, please indicate this)
Follow-up: What is the cure for dementia, high cholesterol and macular degeneration in both eyes while on remeron and synthroid? 6 hours later
Dr. Mittal, Your answer was very well thought out and thorough thank you. I will ask the Pulmonary physician about the Arterial blood gas; I believe that the hospital looked into something like this when my mother aspirated for the first time back in October 2012. My mother's thyroid levels go up and down with each hospital visit and Synthroid adjusted accordingly and I emphasize only because I have Graves disease and had XXXXXXX and am having an extremely difficult time getting regulated on thyroid hormone and I know about thyroid inside and out; very good point thought because they have not test thyroid levels in about 6 weeks now and I will bring up with my mother's nurse today as I also want her sodium levels tested and maybe a urinalysis as she has been very prone to UTIs for 3 years now. Very interesting point about elderly and the vertigo they develop when they rise and fall in blood pressure that becomes more significant in elderly; my mother opted to go with the Assisted Living Facility's Medical Team as the doctor is not geriatric yet the nurse practitioners there have all been super; it is a lot to take her out and bring her to a doctor as she has no clue anymore what her health problems are or why, does not hear and does not want a hearing aide and does not see because of the severe macular degeneration in her both eyes so I'm her eyes and ears and may not always be available to transport her to a doctor; plus they do not communicate with outside doctors so basically family has to hand carry any notes or prescriptions as we use the internal Assisted Living pharmacy which is easier than running scripts to a pharmacy and more timely. So mother has a lot of "specialist" types of doctors (although not an endocrinologist) and they have all been great too. I will ask her to do those things you suggest yet she will forget. My mother does very well as long as rehab is still occurring; yet with Medicare and only certain days allotted and they told me too be careful not to use all the days as she may need them in future in case God forbid she breaks another hip (that was a 2 month rehab back in 2011); Mother's O2 was dropping per an overnight pulse ox ordered by her Pulmonary doctor below 88 for 2 hours; why the overnight oxygen; I agree about the BIPAP machine yet issue yet mother takes the overnight oxygen off all the time and the caregivers have to put it back on her nights every two hours; she was doing the same wearing it daytime at the rehab as I observed. Some of her poor judgment and impulsiveness is due to her dementia and she did not tolerate Exelon patch well; my one sister who was a higher up at the FDA with Generic drugs said that Exelon is one of the better drugs for Dementia too! Hospice in the hospital in May when she almost died from aspirating said to be cautious with how much testing you put her through as it is only going to aggravate her more and with her dementia harder to take; yet I do agree that further testing needs to be done to see if there was a stroke as my other sister an RN works with dementia and Alzheimer's patients over 28 years and says always a possibility mother had some XXXXXXX strokes going on? I apologize as the Spirva is inhale 1 capasule (18 mcg) once daily; the Advair Diskus inhalation disk with device 250-50 mcg/dose is one puff 2 times in the morning and evening approximately 12 hours apart for 30 days.Albuterol sulfate inhalation solution for nebulization 2.5 mg/3 mL 2 times per day and PRN. (which mother would never ask anymore PRN as she forgets and doesn't realize when she is in distress to ask for it.) I apologize as I should have spelt out; AAA - Abdomnal Aortic Anuerysm surgery Dec 2010; not a stent; full open surgery to repair a huge anuerysm; mother was supposed to take care of this 4 years earlier yet opted not to. She was told she was never a candidate for the stent even when the aneurysm was smaller; she was in so much pain and it was terrible and we got her down to the best hospital here south of us MUSC, Medical University of SC; it was a long recovery yet with my helping her, she got through; after that she became depressed and went on Celexa and that threw her sodium levels off; only 3 months after that surgery she fell in February 2011 due to making a poor judgement once again about something; my sister the RN feels the dementia was arising for years before as she said it can be a 10-15 year span yet only subtle signs then yet with more falls and breatihng incidents, etc., in 2013 it seems that the mental aspect has accelerated which I understand; I volunteer over there almost 3 years now and I see the progression; more difficult though when it is your own parent and you have to decide what is best and with my own health struggling too it is not always easy to know what is best; especially since I am POA too and only daughter here. She is bascially unable to make decisions as she has not been able to for 3 years; yet you could meet her and think she is pretty good for 88 years of age; she knows who I am and family; yet that was one question I please would like your input; do you think the medication Remeron could cause more confusion? She is only on 7.5 mg. Yet she seems even more confused after this incident or is it the fact of yet another trauma of a fall (if you saw her back 11/5/13 she was bruised right side head to toe and fractured her right wrist). Yet she once again bounced back; yet it was due to adult failure to thrive also and the Pulmonary medical practitioner said that with that there can come depression and lack of appetite especially with difficult breathing and that the Remeron has really helped her mood and she is eating well again. She could not be on Megace as it can cause DVTs and she is prone to them. So, it seems even though I am not sure about Remeron if it causes confusion, it has had positive results too. She was in a really bad way a couple weeks before the fall as I was telling the facility nurse as there was something wrong again with her breathing and we could not put our finger on it as it was subtle yet if she was malnourished which the hospital said and I was told with COPD this can happen as the patients metabolize foods very quickly and cannot get enough nourishment at times; yet in rehab almost two months they made her take Ensure 3 times a day, intense rehab and watched her eating and it is night and day how she improved in those weeks; yet the confusion and very bad memory persist. So do you think Remeron is causing this? As I see that drug does not have a high risk of confusion (low percent) yet like any of these possibility of sodium imbalances? And what is the alternative as it gets tricky; benefit vs. risk? I printed you answer out and will discuss items with the nurse; I look forward to hearing back once again as I believe I can ask now one more time yet if I find out about the Remeron I do feel that all of the input was excellent, thank you! Or if you need any more information. I also believe that the facility may have a geriatric doctor do rounds a couple times a month at the facility my mother is (it is a corporation and they have AL facilities all throughout the state) as I believe he is super so I am told. I do realize as you suggest further testing is needed! Thank you again and look forward to hearing back from you....XXXX
Answered by Dr. Saumya Mittal 41 minutes later
Brief Answer: Response to some queries, and suggestions Detailed Answer: Thank you XXXXXXX for your confidence in me and my response. I am grateful for that. The arterial blood gas, or the ABG, is a report that changes every minute. So the report that was done in 2012 is now over and you need not bother about it. At that time they must have been looking at the oxygen levels in view of aspiration pneumonia. Our interest right now is in oxygen levels no doubt, but more in the carbon dioxide levels. I agree with your thought that the thyroid levels and sodium levels should be rechecked. Fluctuation of sodium is not something that is very common. I hope she has had an extensive work up of thyroid previously. Otherwise i would have suggested an ultrasound of thyroid to make sure that there are no nodules. If there is something significant in the thyroid ultrasound, a thyroid scam may be planned later. But as you said, you know about thyroids and so I am sure this has been done. As for sodium test, i would say that despite the fact that hyponatremia is frequent in the elderly, maybe she is losing some salt in her urine, and probably that can be tested via the spot urine sodium test. And a urine test to rule out a urinary tract infection will be a very good idea indeed. I am assuming her sugars have been tested and are normal. I have another suggestion. You said she keeps forgetting things. And i understand she has reading as well as hearing problem. I suggest that you record or write a diary, whichever modality of her external senses is better, so that she can have a look at the notes, or hear the notes and follow them more regularly. You also said the nurses there are very cooperative. Maybe if they keep reminding her, it will become a habit. I suppose it is too much to ask of an elderly person who is not in the best of health to form a new habit. But i guess it’s worth a try. Her inhaler dose seems to be fine. I would agree with a similar dose in my patients. As far as falling saturations are concerned when she is recumbent, you can try, if she is comfortable to let her sleep in a semi sitting position- something between a sitting and sleeping. Maybe this will help her breathe better. Having said that, i am not too sure about her ejection fraction, or the amount of blood pushed in the body by the heart. If it is low, she will develop breathlessness about 2-3 hours after lying down. The fluid collection in her lungs can cause a fall of saturation. If not previously done, maybe an echocardiography can be planned. If this turns out to be the case, simple diuretics may help her. I would also suggest starting incentive spirometry. I cannot give a clear answer about Remeron. You see what happens is that the usual dose she is getting is low, agreed. But there is a possibility that for her, in her elderly age, and possibly lower metabolism and weight, the dose is getting accumulated and she is getting drowsy. But I cannot at all be sure about this aspect till i have seen her in person. Besides as you have said, she seems to have increased. So it is essentially between the good that the tablet is doing and the harm that it is doing. And only someone who is managing her directly can decide about that. The possibility of drowsiness, and hence confusion is there. But as you have admitted, she is doing better. And there are other causes of confusion present. Not just hyponatremia. But possible hypoxia, hypercarbia, fluid overload (as i explained in relation to the echocardiography), thyroid disorder, repeated infections (urinary tract infections) all can contribute to confusion. Having said that, the possibility of Alzheimer’s disease and Stroke has to be kept in mind. Now i agree if they are there, we can maybe not do too much about the damage done. But then we can probably do something to avoid further episodes. I hope your geriatrics doctor can contribute towards your mother’s treatment. Always willing to help you and answer any possible further queries, Yours sincerely Dr Saumya Mittal
Follow-up: What is the cure for dementia, high cholesterol and macular degeneration in both eyes while on remeron and synthroid? 8 hours later
Thank you very much Dr. Mittal for your response. I did mention it to my mother's nurse today about the ABG; she said definitely bring it up to the Pulmonary Specialist; we go again in a few weeks. She is already ordering the TSH test; mother had thyroid scans many years ago; only got on Synthroid back about 8 years ago. Levels do fluctuate it seems with each trauma and hospital visit. Very good suggestion thank you. They will do urine as if she seems very confused again; they are carefully monitoring her since she just came back from skilled nursing/rehab back to assisted living yesterday; I spoke with the nurse for a while and especially after reading your original comments. Yes sugar is normal; my father had issues and now I am following suit after XXXXXXX for Graves side note; mother's side was the higher cholesterol. Excellent suggestion; repetition with the elderly I am finding is good and yes very large notes; mother has this huge reader she hardly uses any more for her severe macular degeneration yet if I print notes out very large in Powerpoint it helps. In spite of all the problems and basically almost passing on two times in the last year, my mother is very motivated; she has had physical therapy now off and on for three years and kind of almost gets excited over it where other elderly don't want to be bothered; it is good thing; yet when it runs out that is when she weakens especially if she declines activities there and sits in her room. I think the Remeron is definitely helping her mood and her appetite as I see a big difference as right before and after this fall she seemed like she wanted to die; especially with not eating too! Yet now even with some confusion she does not want to stay in that wheelchair and wants to get right back up on her rollerater walker which has the basket (not the metal walker which she dislikes); she is really amazing yet there are health problems, physically and mentally she really is not aware of; I would say end of 2011 was the last time my mother really totally understood the impact of any physical probelms she has; her body is so compressed with the kyphosis (scoliosis) type and that small hiatal hernia probably doesn't help that her lung capacity is diminishing and also with all the breathing incidents and she is just shrinking; sure rehab tells her to sit up straight and in her chair too yet she forgets; they give her notes of exercises to do in her room yet she forgets; she hates that spirometer that her Pulmonary doctor wants her to use; I guess a bit of stubborness too and with not realizing the extent of her health problems no clarification of why to do all these things; or should I say she forgets what is going on and tells everyone like doctors she has no breathing or physical problems and why all the fuss; like she forgot she fell 11/5/13 (as an example of what happens in the last year, four different incidents) and that why is she moved around so much from hospital to rehab and back to the AL? Or that she was not eating well. Or that she was depressed. Mother's heart was tested with stress test in Spring 2013 and her results were super. It is all Pulmonary which of course if not treated right heart could get affected. She's had CTs of her brain after two falls this year and nothing comes up as I expect they'd see if there was a stroke? Or is the MRI better? I try to get her to sit better too especially for napping yet difficult that she does what she wants. She was on Lasix almost two year, 20 mg and then down to 10; started causing some imbalances and they took her off of it. Lots of problems with incontinence, then using pads and getting UTIs and maybe too having a Pessary did not help. The fluid that was in her ankles after the Abdominal Aortic Anuerysm surgery in 2010 is gone; just some swelling down by the feet which is strange yet I hear elderly get this too as I'm going to a class on this over where my mother lives this Thursday evening. Excellent point about weight gain, metabolism slowing with Remeron; thus possible confusion resulting. Since mother is so very sensitive to any medications, the woman who was on nothing her entire life except Synthroid back 8 years ago and then at 85 all of a sudden all these problems and medications. She would not even take Tylenol most of her life; and then all these medications and side effects. She has had very good effects from Remeron; the nurse said of the concerns I have that they will keep a careful eye on her for side effects or more confusion. They know her well over there which is a good thing although there have been some newer caregivers and med-techs hired since she was gone to rehab 2 months. I know they did echocardiogram in the hospital too this time around; I was there a lot at the hospital and they did all kinds of tests on my mother. You are absolutely right so many factors could be contributing. It is very difficult to pinpoint especially one thing; plus prior to this hospital / rehab stay about 2 weeks mother was seeming somewhat lethargic and confused and she was bascially on minimal medications as mostly supplements. That is exactly as a daugther and POA trying to avoid future breathing incidents and falls; yet I do realize as they age and with a lot of incidents it weakens them too; that is one thing I did forget to ask after being with the nurse over an hour today about that Geriatric doctor; I know there are 2 super nurse practitioners coming in now weekly off and on and well the doctor who has been coming is not as thorough as some so I look forward to that Geriatric doctor making rounds or I may just decide to send mother out to a Geriatric doctor I know who is super in our town right nearby her home there at the AL. Thank you again so much; I just keep learning and knowing from a problem I had last Spring using this service that there are excellent doctors who can give some very good medical input as I've been thorough about a lot with mother's care yet I never stop learning as I am not a medical person and now I have even more information to utilize toward assisting with proper health care for her! Thank you very much again!XXXX
Answered by Dr. Saumya Mittal 3 hours later
Brief Answer: mri is better than ct scan Detailed Answer: Hi XXXXXXX thanks for continuing with XXXXXXX I have noted all the details you mentioned for future use. I must say that you are quite meticulous in the details. I am glad you like my ideas. Yes, an MRI is a better investigation tool than a CT scan. It does give us more information. As of now, I can probably just say that let me know the reports. So I can probably help you further thereafter. Best of Luck Dr Saumya Mittal