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Mental Health and Dementia--House of Cards or House on Fire

For those of us who have worked one-on-one with seniors in their own homes or in communal living situations or hospitals, we all have a story (or one hundred) about a patient or resident who had a mental health moment. In dealing with human beings, no matter what their age, there's no telling what might happen on any given day. Whether you believe it or not, the moon and the weather also seem to play a part on a typical day in senior living. Some nurses I know swear by the full moon indicator that the residents or patients will "go nuts" during that time of the lunar cycle.

There are many reasons for a person, elderly or not, to "go nuts". This does not always indicate a mental health disorder; however, there are plenty of undiagnosed and under-diagnosed seniors living with mental health issues that are generally exacerbated by other health issues, including dementia.

Do They Have a U.T.I?

In speaking with families who are in crisis mode due to a sudden change in their loved one's behavior, one of the first things I always ask is if they are prone to urinary tract infections. Though a younger person with a U.T.I will feel discomfort, elderly people don't always feel the pressure, pain or discomfort that will generally accompany this common diagnosis. What they will display is strange behavior, sudden onset of delirium or confusion and dizziness which can lead to frequent falls. It's important to get your loved one treated for the infection and keep a close eye as symptoms can return quickly if they relapse.

Any type of infection can affect how a senior behaves or experiences the world, and if a person has a mental health moment due to an underlying infection, it's not often recommended that they receive behavioral health consultation following their recovery as long as the condition doesn't continue after they recover.

Are they Dehydrated?

Dehydration can cause the brain to do crazy things. Elderly are more likely to suffer from dehydration without feeling thirsty. Always offer a drink of water or a beverage with electrolytes if you notice your loved one is behaving strangely. Even if it's something else, a little drink (of water) won't make it worse.

Are They Sundowning?

Sundowning or Sundowner's Syndrome, though not a disease, it's a set of symptoms and it affects seniors who may already have a dementia diagnosis. It is marked by increased confusion and agitation later in the day. It may be due to lack of natural light, hunger or thirst, fatigue, or all of the above. If your loved one is suffering with symptoms that get worse in the later hours of the day, it's suggested to encourage a consistent schedule, plenty of exercise, natural light, no caffeine in the afternoon, and resting during the day. If they are already in the throws of a sundowning episode, the National Institute on Aging suggests reducing noise and clutter, adjusting lighting to a softer light or natural light, and distracting them with a snack and drink to try to ease the anxiety.

Sundowning can be disruptive and scary, but it doesn't always immediately warrant a behavioral health consultation. If you feel that your loved one is really struggling beyond what is manageable, there are prescription medications that can help diminish the symptoms, but it's important to know that these should be monitored by a geriatric psychiatrist or behavioral health nurse practitioner.

Depression is NOT a natural part of aging

According to the CDC, 1%- 5% of healthy seniors experience major depressive disorder. The percentage raises to 13.5% for those who require home healthcare and 11.5% for those who are hospitalized. Overall, these percentages are pretty low. For seniors who suffer with depression, they may have struggled for their whole lives, and most likely they may have had episodes at other times in their life. It's important to know if your loved one is prone to assist them in receiving help from a behavioral health practitioner. Symptoms of major depressive disorder include, isolation, disinterest in things they used to enjoy, speaking of suicide or death, unplanned weight changes, among others. Seniors with major depressive disorder may no longer be able to mask their symptoms, so it's important to pay attention.

Depression IS common with Alzheimer's and related dementias

If your loved one is suffering with dementia, depression is usually a part of it, and there are medical treatments that can help. Most people start with a neurological appointment when they notice symptoms of memory loss. I strongly encourage finding a good geriatric behavioral health provider to help monitor mental health and medications related to stabilizing symptoms. Psychotherapy is often helpful in the early stages of the disease also, as the person is struggling to come to grips with the diagnosis and changes that are taking place.

Psychotic Episode! What now?

With onset of brain loss, psychotic episodes including hallucinations may happen. This can be incredibly disturbing to someone who has never experienced it. Due to the degeneration of the frontal temporal lobe, a person may not be able to decipher reality as they once did. This can be challenging for caregivers and family. If your loved one is suffering with a sudden onset of psychotic episodes and not being able to decipher reality, it's important to get an appointment with a health care provider, preferably a behavioral health specialist as soon as possible. It's also important to know what First-Episode Psychosis is. The Pennsylvania Department of Human Services has a program designed to educate the public about First-Episode Psychosis and offer resources. Information can be found here:

What to do if your loved one won't get the help they need

Unfortunately, unless you have guardianship of your loved one, or at the very least health care power of attorney, it's difficult to have someone committed to a short term stay at a behavioral health facility against their will unless they prove that they are a danger to themselves or others. There are short term behavioral health hospitals that specialize in geriatric patients. A stay at a geriatric behavioral health hospital will generally last a couple weeks to a month and it is covered by insurance. It can be a game changer for regulating medications and returning the patient to a more manageable baseline.

If you are in crisis and don't know what to do, always call 911 first and try to have an ambulance take them to the emergency room. At that stage they will have a consultation and hopefully be able to be placed for a short term stay at behavioral. Involving first responders will at least alert the jurisdiction that there is a problem. This doesn't always work and sometimes, your loved one may convince the doctors that he/she is fine and should be released. If this happens, you may want to involve your local office on aging for additional resources.

Validate and Re-Direct

As mentioned in previous posts, the best way to de-escalate a psychotic episode is to validate your loved one's fears or claims, even if they aren't true. Arguing with someone who is in this state is only going to upset everyone further. Tell them you understand what they are saying and seeing and ask them what you can do to make things better. Listen to what they say and let them know you are sorry that things are so bad for them and that you are doing everything you can to fix it. If they start to calm down a little, then attempt to distract them with something else like a book of old photos, a snack and a drink, or a funny television show. I find that if someone is incredibly agitated, they will be less likely to be validated and they may just argue with anything you say, regardless. In this case, they are unlikely to be re-directed so you may need to call in first responders. The good news is if they are this bad, they may have a better chance of being admitted and then a better chance of being discharged to a behavioral health hospital.

Be mindful of knock-out drugs

If your loved one is a danger to themselves or others, the hospital may heavily sedate them, which is okay for the short term, but you need to advocate for them to get the appropriate treatment and three days of sedation isn't always necessary for someone with dementia who had a psychotic episode. Keep a close watch and ask plenty of questions about the treatment plan. If something doesn't seem right, keep asking and demanding answers. Your loved one shouldn't be knocked out the whole time they are in the hospital. Providers don't seem to have time to deal with elderly dementia patients with psychotic outbursts so they tend to throw medication at them. Unfortunately for the hospital, they may have to provide a one-on-one for your loved one if they don't have a secured floor, which is why so many elderly dementia patients end up sedated at the hospital.

As mentioned above, there are behavioral hospitals that specialize in geriatric patients. Do some research in your area to see if there is space available and what the stay might look like for your loved one. Much like a regular hospital, a geriatric behavioral health hospital will have a social worker who will help with safely discharging your loved one back home or to a secured memory care community.

If you choose to move your loved one to a secured memory care community, ask if there is a behavioral health service that sees patients in the community. It's important to keep a close eye on medications and changes for a person who is suffering from dementia with psychotic episodes. If medications are regulated, they can often live the rest of their days in relative peace, but just because something works today, doesn't mean that it will work tomorrow. Having a good behavioral health provider can alleviate the trial and error and guess work that a general practitioner will recommend.

Aging doesn't come in a one-size-fits-all. Every day we learn and grow together. Knowing what to expect may help you better navigate mental health and dementia.

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