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5 Types of Medication Used to Treat Sundowning & Difficult Dementia Behaviors

One of the greatest challenges, when it comes to Alzheimer’s disease and other dementias, is coping with sundowning and with difficult behaviors.

These are symptoms beyond the chronic memory/thinking problems that are the hallmark of dementia. They include problems like:

Delusions, false accusations, paranoid behaviors, or irrational beliefs
Agitation (getting “amped up” or “revved up”) and/or aggressive behavior
Restless pacing or wandering
Disinhibited behaviors, which means saying or doing socially inappropriate things
Sleep disturbances

These are technically called “neuropsychiatric” symptoms, but regular people might refer to them as “acting crazy” symptoms. Or even “crazy-making” symptoms, as they do tend to drive family caregivers a bit nuts.

And when these behaviors happen in the late afternoon or early evening, it’s usually called “sundowning“. (In most cases, sundowning is triggered by fatigue; anticholinergic medications may cause sundowning symptoms as well.)

Because these behaviors are difficult and stressful for caregivers — and often for the person with dementia — people often ask if any medications can help.

The short answer is “Maybe.”

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4 Types of Brain-Slowing Medication to Avoid if You’re Worried About Memory

by Leslie Kernisan, MD MPH

A few years ago, while I was at a family celebration, several people mentioned memory concerns to me.

Some were older adults concerned about the memory of their spouses. Some were adult children concerned about the memory of their parents. And a few were older adults who have noticed some slowing down of their own memory.

“But you know, nothing much that can be done at my age,” remarked one man in his eighties.

Wrong. In fact, there is a lot that can and should be done, if you notice memory or thinking changes in yourself or in another older adult. And you should do it because it ends up making a difference for brain health and quality of life.

First among them: identify medications that make brain function worse.

This is not just my personal opinion. Identifying and reducing such medications is a mainstay of geriatrics practice. Among other reasons, we do find that in some people, certain medications are causing memory loss symptoms — or other cognitive symptoms — to be worse.

And the expert authors of the National Academy of Medicine report on Cognitive Aging agree: in their Action Guide for Individuals and Families, they list “Manage your medications” among their “Top 3 actions you can take to help protect your cognitive health as you age.”

Unfortunately, many older adults are unaware of this recommendation. And I can’t tell you how often I find that seniors are taking over-the-counter or prescription medications that dampen their brain function. Sometimes it’s truly necessary but often it’s not.

What especially troubles me is that most of these older adults — and their families — have no idea that many have been linked to developing dementia, or to worsening of dementia symptoms. So it’s worth spotting them whether you are concerned about mild cognitive impairment or caring for someone with full-blown Alzheimers.

Every older adult and family should know how to optimize brain function. Avoiding problem medications — or at least using them judiciously and in the lowest doses necessary — is key to this.

And don’t give anyone a pass when they say “Oh, I’ve always taken this drug.” Younger and healthier brains experience less dysfunction from these drugs. That’s because a younger brain has more processing power and is more resilient. So drugs that aren’t such problems earlier in life often have more impact later in life. Just because you took a drug in your youth or middle years doesn’t mean it’s harmless to continue once you are older.

You should also know that most of these drugs affect balance, and may increase fall risk. So there’s a double benefit in identifying them, and minimizing them.

Below, I share the most commonly used drugs that you should look out for if you are worried about memory problems.

Featured Download: Get my free list of medications that can affect memory and thinking in aging adults. This handy PDF includes all the medications I usually check for. Click here to download.

The Four Most Commonly Used Types of Medications That Dampen Brain Function

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How to Detect & Treat Vitamin B12 Deficiency in Older Adults

by Leslie Kernisan, MD MPH

Everyone knows that vitamins and nutrition are important for health, and many older adults take a multivitamin.

But did you know that even among older persons who do this, many still end up developing a serious deficiency in one particular vitamin?

It’s Vitamin B12.

If there’s one vitamin that I’d like all older adults and family caregivers to know more about, it would be vitamin B12.

(Second on my list would be vitamin D, but it’s much harder to develop low vitamin D levels if you take a daily supplement, as I explain in this post. Whereas vitamin B12 deficiency does develop in many older adults who are getting their recommended daily allowance.)

A deficiency in any vitamin can be catastrophic for health. But vitamin B12 deficiency stands out because a) it’s very common — experts have estimated that up to 20% of older adults may be low in this vitamin — and b) it’s often missed by doctors.

Geriatricians also like to pay attention to vitamin B12 because a deficiency can cause — or usually worsen — cognitive impairment or walking problems.

But if you know the symptoms and risk factors, you can help ensure that you get a vitamin B12 deficiency detected. Treatment is safe and effective, as long as you catch the problem before permanent damage occurs. Here’s what to know.

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How to Plan for Decline in Alzheimer’s Dementia:
A 5-Step Approach to Navigating Difficult Decisions & Crises with Less Stress

by Leslie Kernisan, MD MPH

Q: My mother is 76 and has Alzheimer’s disease. She had a couple of unavoidable stays last year in the hospital (due to falls). This accelerated her decline due to delirium, which was treated as if she was just being an unruly and difficult patient. Once my sister and I understood what was going on due to this site’s information, we have been able to protect and support her.

Right now things are stable and quiet, so we are trying to plan ahead.

How should we go about planning for the years of decline my mother may experience before her actual last moments near death? It’s hard to imagine this possibility and I need help facing the (to me) not so obvious.

We have a will, power of attorney, and health care proxy in place.

A: Great question, and especially good that you’re taking advantage of a “quiet period” to address these issues.

It’s a little tricky to answer this question without knowing more about your mother’s current ability to participate in decision-making and in planning for her future care.

Since you say she’s declined after hospitalizations for falls and delirium, let me assume that she has moderate Alzheimer’s and can’t manage more than perhaps expressing some of what she likes and doesn’t like. (For more on the stages of Alzheimer’s and related dementias, see here.)

At this point, you’ve been through some health crises already, and you’ve seen her decline. You’ve also probably gotten a sense of just how many decisions have to be made on her behalf. Some are about her medical care and some are about other aspects of her life, like where she lives and how she spends her days.

Planning ahead is an excellent idea. Obviously, it’s simply not possible to anticipate and plan for every decision that will come up.

But let me offer you an approach that you can use both now as well as “in the heat of the moment” when specific issues arise. This is a framework to help you navigate all kinds of care decisions and future crises that you may encounter.

The following five steps will give you a foundation for anticipating, processing, and reacting to the complications and problems of later-stage Alzheimer’s, with less anxiety and more confidence. These steps are:

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Q&A: What to do if your aging parent becomes rude & resistant

by Leslie Kernisan, MD MPH

Q: My loving, Jewish mother is 92 and has turned into a rude, abusive foul-mouthed woman who I no longer recognize.

She’s in relatively good health and amazingly lives in the same house I grew up in. She has an aide during the day. She won’t leave the house,treats the aide poorly and last weekend cursed out my very patient spouse. We’ve been getting 5 calls a day such as ” I”m having a heart attack; no one will tell me whether recycling comes today”!

I know she has early signs of dementia. Her cardiologist tells me not to take it to heart and this is not the same women who raised me. She won’t go to the JCC adult programs, complains about being lonely at night, yet hangs up on me when I tell her we can get an aide at night or sell the home and let her live in a facility with women her age, etc. She threatens to call the Police if someone comes to her home at night. I have a POA but don’t want to rob her of her independence at 92. I try to tell her to speak nicely to the aides, myself, my spouse, but she says ” I don’t remember or I must have reacted to something someone did or said.”

I feel guilty as I’m not spending as much time with her as I would like, but it’s a matter of survival. Jewish guilt is thrown about with impunity and I can’t tell whether she’s being manipulative and obsessing over bullshit ( “oh my God the outside light may burn out tonight” ) or she really can’t control herself. Her aide is a lovely human being but my mom orders her around like a slave. Who is this woman? I’m torn, anguishing over what to do and am doing nothing but try to correct her inappropriate behavior and language. I wanted to take her to a geriatric psychiatrist but she refused to go. Medication to calm her down is dangerous per the MD as she could fall, etc.

What should I do? I’m at my wits end.

Dr. K’s answer:

Wow, difficult situation but unfortunately not uncommon.

You say your mother has early signs of dementia, and it is true that “personality changes” can be due to an underlying dementia, such as fronto-temporal dementia or Alzheimer’s, especially if a family notices other changes in memory or thinking abilities.

But it doesn’t sound like your mother’s been clinically evaluated for dementia, and you don’t say whether this has been brought up with her primary care doctor.

How to Get Memory & Thinking (or Personality Changes) Evaluated

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Incompetence & Losing Capacity:
Answers to 8 FAQs

by Leslie Kernisan, MD MPH

Depositphotos_9669220_m-2015-brain-cogs-leaving-compressor

Have you ever been concerned about an older relative who seems to be making bad decisions?

Perhaps your elderly father insists he has no difficulties driving, even though he’s gotten into some fender benders and you find yourself a bit uncomfortable when you ride in the car with him.

Or you’ve worried about your aging aunt giving an alarming amount of money to people who call her on the phone.

Or maybe it’s your older spouse, who has started refusing to take his medication, claiming that it’s poisoned because the neighbor is out to get him.

These situations are certainly concerning, and they often prompt families to ask me if they should be worried about an older adult becoming “incompetent.”

In response, I usually answer that we need to do at least two things:

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7 Steps to Managing Difficult Dementia Behaviors
(Safely & Without Medications)

by Paula Spencer Scott

(This article is by my colleague Paula Spencer Scott, author of the book Surviving Alzheimer’s: Practical Tips and Soul-Saving Wisdom for Caregivers. I invited her to share an article on this topic, since many in our community are coping with dementia behaviors. — L. Kernisan)

The odd behaviors of Alzheimer’s and other dementias can be so frustrating and stressful for families.

I’m talking about the kinds of behaviors that try patience, fray relationships, and drive us in desperate search of help:

“First she thinks the caregiver is stealing her sunglasses and now she accused me of having an affair.”

“When I tried to help Dad wash up, he hit me.”

“My husband follows me so closely I can’t stand it. But if I go in another room he’ll wander out of the house.”

“Mom started unbuttoning her shirt in the middle of the restaurant!”

“Just when I’m completely exhausted at the end of the day, he seems to get revved up. He keeps peeking out the windows, convinced that someone is trying to break in. Now he won’t sleep.”

A common approach to difficult behaviors is to go right to medicating them with tranquilizers, sedatives, or antipsychotics. But that’s risky and often not what’s best.

In fact, experts recommend trying behavior management first, and for good reasons: It tends to be more effective in the long run than “chemical restraints,” has no dangerous side effects, and leads to a better care relationship. But people often don’t know how to do this.

I’ve learned how.

I’ve lived through five close family members’ experiences with Alzheimer’s and other forms of dementia. Lots of trial and error, and insights from dozens of top dementia experts (whose brains I’ve been lucky to pick as a journalist and dementia educator), got me through regular scenes with…

My father-in-law, who needed a walker to move yet spent hour after hour for several days straight hauling all his clothes and toiletries from his room to our driveway, insisting that his (imaginary) new wife was about to pick him up
My dad, a formerly sharp dresser who wore the same shirt and pants every day no matter how dirty
My grandmother, who insisted on going “home,” when she was home
And other relatives, in dozens of similar scenes.

In this article, I want to share what I wish someone had explained to me early on: the “Why-This, Try-This” approach to dealing with difficult behaviors.

This is a mental framework that can help you get unstuck from unproductive responses that get you nowhere or make things worse.

It can bring calm -– to both of you — whether the issue is verbal or physical aggression, agitation, confusion, wandering, disinhibition, delusions, hallucinations, or a restless or repetitive behavior (like pacing, shadowing, rummaging). It also works well with milder irritants like repetitive questions and indecision.

Then, I’ll boil down the Why-This, Try-This concept to a 7-step process you can use every time. These “7 R”s give you a basic platform for responding to any frustrating behavior:

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Q&A: Hospice in Dementia, Medications, & What to Do If You’re Concerned

by Leslie Kernisan, MD MPH

Q: Dear Dr. K,

With all the news about opioids and benzodiazepines, and their risk of death, I would love to hear your take on the use of these drugs in hospice.

We’ve had two family experiences now (my Mom and my Aunt) who were given these drugs right away when they went on hospice…without hospice trying anything else first that would be less dangerous. My Mom was up and about walking one day at her memory care facility, even laughing. The next day, when hospice put her on morphine and Ativan, she was in a coma. She died 13 days later without ever regaining consciousness. When I protested and asked why she wasn’t waking up, the hospice nurse said, “It’s not the drugs, it’s the disease.” (Mom had dementia.) The nurses wouldn’t let us give her fluids (“you don’t want your mother to aspirate, do you?”) or feed her (“you don’t want your mother to choke, do you?”).

With my Aunt, she had also been in the memory care facility and got to the point of needing a two-person assist. Her power of attorney (POA) was given the choice of moving my Aunt into a nursing home or bringing in hospice. Hospice immediately gave her morphine and Ativan, then backed off the Ativan and gave her morphine every two hours until she died 3 days later.

Now the third sister, also with dementia, has been in hospice for two months and counting. She is lucid most days, eating/drinking, comfortable—all without the opioid/benzo drug combo, because of our experience.

How can family members identify a hospice that doesn’t use this troubling combination of drugs from the start, without first trying something less dangerous, to make a patient “comfortable”?

A: Thanks for sending in this question. I’m very sorry to hear that your experiences with hospice have left you concerned.

It is indeed extremely common for hospice to use morphine and lorazepam (brand name Ativan) to treat end-of-life symptoms. That’s because many people on hospice are suffering from troubling symptoms that these medications can relieve, such as pain, shortness of breath, anxiety, and agitation.

Still, these medications are not always necessary. They are supposed to be prescribed and used as required to relieve the dying person’s symptoms, not by default. So the situation you describe with your mother and your aunt does sound potentially concerning. At a bare minimum, the hospice personnel should have done a better job of discussing their proposed care plan with your family.

Now let me be clear: I cannot say if the way they prescribed morphine and lorazepam was inappropriate or not, because it’s impossible for me to know the specifics of your mother and aunt’s medical situation.

Still, we can certainly review some basics about hospice care for people with Alzheimer’s and related dementias, as well as recommended best practices, when it comes to using opioids and benzodiazepine sedatives.

Here’s what I’ll cover:

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8 Behaviors to Take Note of if You Think Someone Might Have Alzheimer’s

by Leslie Kernisan, MD MPH

Have you been worried about an older person’s memory or thinking skills? If so, you’ve probably found yourself wondering if this could be Alzheimer’s, or another dementia.

What to do next? If you look online or ask people, the advice is generally this: tell the doctor.

This advice isn’t wrong, but it’s incomplete. Yes, you should tell the doctor. But you’ll dramatically improve your chances of getting to the bottom of things if you come to the doctor with useful information on what you’ve observed.

In fact, research has found that interviewing family members about the presence or absence of eight particular behaviors can be just as effective, when it comes to detecting possible Alzheimer’s, as certain office-based cognitive tests.

8 Alzheimer’s Behaviors to Track

For each of these behaviors, try to make note of the following:

Whether there’s been a decline or change compared to the way your parent used to be
Whether this seems to be due to memory and thinking, versus physical limitations such as pain, shortness of breath or physical disabilities
When you – or another person – first noticed problems, and what you observed
What kinds of problems you see your parent having now

If you don’t notice a problem in any of the following eight areas, make a note of this. (E.g., “No such problem noted.”) That way you’ll know you didn’t just forget to consider that behavior.

Have you noticed:

Signs of poor judgment? This means behaviors or situations that suggest bad decisions. Examples include worrisome spending, or not noticing a safety issue others are concerned about.
Reduced Interest in Leisure Activities? This means being less interested and involved in one’s usual favorite hobbies and activities. You should especially pay attention if there isn’t a physical health issue interfering with doing the activity.
Repeating Oneself? Has your parent started repeating questions or stories more than he used to?
Difficulty Learning to Use Something New? Common examples include having trouble with a new kitchen appliance or gadget. This can be a tricky one to decide on, given that gadgets become more complicated every year. But if you’ve noticed anything, jot it down.
Forgetting the Year or Month? Especially once one stops working, it can be easy to lose track of the date or day of the week. But if you notice your parent forgetting the year or month, make a note of this.
Difficulty Managing Money and Finances? Common examples include having trouble paying bills on time, struggling to balance the checkbook, or otherwise having more difficulty than one used to have managing finances.
Problems with Appointments and Commitments? If you’ve noticed that your parent is having more trouble keeping track of appointments and plans, make note of this.
Daily Struggles with Memory or Thinking? It’s normal for older adults to take a little longer to remember things, since many brain functions do slow a bit with aging. But it seems that your parent often can’t remember things that happened, or otherwise seems to be more confused with thinking, make note of this.

For more on diagnosing Alzheimer’s and other dementias

If you’re worried that your older relative might have dementia, I recommend you learn more here: How We Diagnose Dementia: The Practical Basics to Know
My book, “When Your Aging Parent Needs Help“, also comes with worksheets to help you check for signs of dementia, a handy checklist of what information to bring to the doctors, and more.
In this Youtube video I share 10 early warning signs of Alzheimer’s Disease that often catch my attention, and what to do if you’ve noticed these warning signs.
&lt;br>In this Youtube video, I cover 21 signs and behaviors that families sometimes assume are “normal aging,” but in fact are usually signs of a brain health disorder. It includes the 8 behaviors listed in this article, and many more.&lt;br>&lt;iframe title=”YouTube video player” src=”https://www.youtube.com/embed/JUCiIDVTshA” allowfullscreen=”allowfullscreen” width=”560″ height=”315″ frameborder=”0″> &lt;p> &lt;/p> &lt;div id=”om-girvurusa26deszylwx0-holder”> &lt;/div> &lt;wp-block data-block=”core/more”>
In this Youtube video, I cover 21 signs and behaviors that families sometimes assume are “normal aging,” but in fact are usually signs of a brain health disorder. It includes the 8 behaviors listed in this article, and many more.

Remember, being proactive usually leads to better results and less stress overall!

Delirium: How Caregivers Can Protect Alzheimer’s Patients

by Leslie Kernisan, MD MPH

This week’s Q & A call was about how to better manage health and healthcare issues, when you’re taking care of someone with a dementia such as Alzheimer’s.

Most of the caregivers’ questions were about delirium. This is the state of worse-than-usual confusion that people can develop when they are sick or under serious stress.

I love talking to Alzheimer’s caregivers about delirium, because this is a really common problem that family caregivers absolutely can do something about!

The key is to know that people with dementia are especially prone to get delirium when they fall ill (especially in the hospital). And then you’ll want to know the basics on how to spot this problem, and how to get the doctors to address it properly.

A fact I wish more caregivers of elders knew: delirium can be the only obvious sign of a potentially serious health problem, such as a heart attack, a urinary tract infection, or a pneumonia. (Especially when it comes to older people with Alzheimer’s, they often don’t voice focused complaints the way younger people do.)

The trouble is, even though delirium is very common in older adults, studies have shown that it’s often missed by doctors and nurses. This is a important problem in healthcare, for three key reasons:

[Read more…]

The Four Most Commonly Used Types of Medications That Dampen Brain Function

Dr. K’s answer:

How to Get Memory & Thinking (or Personality Changes) Evaluated

8 Alzheimer’s Behaviors to Track

For more on diagnosing Alzheimer’s and other dementias

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