The Paradox of Medications
By Florence Stafford D.S.W.
Many people have strong feelings about drugs or medications. Some avoid taking any, even when they're medically necessary. Some demand them even when the doctor doesn't recommend any. These contrasting attitudes are found not only among the general population but among professionals in the health field as well. There are some doctors who will prescribe drugs freely for every complaint, such as nervousness, sleeplessness, or tiredness. There are some, however, who prescribe very few drugs.
Why should there be such differences in attitudes and practice? And how do these different beliefs affect mentally impaired patients?
We will be examining the issues concerning the medicating of the mentally impaired as well as the concerns about the drugs prescribed for mental and behavioral problems of the older persons whose mental impairment has been diagnosed.
The majority of drugs now used for mental conditions have been available only since the mid-1950's, and the most effective medications are for depression, anxiety, agitation, and thought disorder. However, all of these medications require careful monitoring since they all have some potential side effects that may be uncomfortable or even dangerous. The challenge to the physician and the responsible family is to find the medication that presents the least risk and still can effectively ease the upsetting mental symptoms.
The most common mental disorder in old age is depression. It is no surprise that depression affects an older person who becomes aware of his deteriorating mental abilities. This is called a reactive depression, since it is in reaction to a problem beyond the control of the older person. A very normal reaction to a very serious problem, this depression can be treated even when the other mental losses may be irreversible.
There are, though, several obstacles that may keep an older person from being medicated appropriately for depression. First, the doctor may assume that the symptoms are part of the total symptoms of chronic organic brain syndrome, and therefore not treatable. Next, if the doctor does decide to try an antidepressant, he must choose among several types and many brands, such as Tofranil, Pertofrane, Elavil, Nardil, Marplan, and Parnak. There then has to be careful monitoring, with feedback to the doctor on the reaction of the older person so that the dosage can be modified, if necessary, or the medication changed altogether. This requires both a genuine interest on the part of the doctor and a generosity about the time needed for discussing the effects of the drugs.
A common error in prescribing for the older person involves the dosage selected for a particular drug. Most recommended dosages are geared to an "average person" who is usually of average weight and young to middle-aged.. The depressed older person may be underweight, since lack of appetite can accompany depression, or overweight, since inactivity is also common. These factors would sharply influence the size of the dosage of effective medication. Furthermore, the older person's changing physiology causes drugs to be absorbed and utilized differently from the way they might be in younger people. As noted, this is due to slower liver and kidney function as well as to changes in the heart, lungs, and circulatory system. In addition, in the older person there may be a higher proportion of body fat where drugs might be stored when not excreted normally. It is obvious why many errors might occur in prescribing for an older person even when he appears to be functioning normally.
Even if the medication is prescribed and is being taken in the correct dosage, there can still be detours on the road to effective treatment. Many antidepressant take up to three to four weeks to be effective. The older person who continues to feel depressed for weeks may become discouraged and refuse to continue with the medication. Or the family supervising the medication regimen may discontinue it after a few weeks if it is unaware of the period of time required for the effects to be seen.
There are also side effects to be considered. Some old people may develop dry mouth, nasal congestion, constipation, urinary retention, and sexual impotence in response to an antidepressant Many antidepressants cause drowsiness or dizziness because of a drop in blood pressure, and this can lead to falls. Some can cause irregular heartbeat, blurred vision, and eye pain. In some old people there can be a toxic effect that causes hallucinations.
Sometimes the antidepressant medication has an opposite effect to that which is intended [called a paradoxical reaction], and increases the depression instead of lessening it. Other times it can worsen the symptoms of mental confusion and disorientation.
With all of these potential adverse effects, you can understand why some doctors hesitate even to start a patient on such a medication regimen, or why they may discontinue it at the very fist report of an unpleasant side effect. The knowledgeable family should report any of these complaints and should not be shy about asking the doctor to try another medication if he does not suggest it himself. Sometimes three or four different medications of varying strengths must be tried before one is found that will help.
Of course, treating depression with medication is no substitute for contact with concerned people, but the relief produced by the medications can make it easier for the older person to respond to the concerned people around him [if his degree of brain failure permits]. In this respect, the purpose of drugs is to minimize the degree of infirmity that is affecting the mentally impaired older person.
A very important area for family vigilance is awareness of any alcohol that the older person might be consuming. While moderate use of alcohol is considered helpful in maintaining good health in a relatively alert older person, it can be very harmful to someone who is mentally impaired. Wine, beer, or hard liquor can have very serious interactions with medications, especially antidepressants and sedatives. Check with the pharmacist or physician for advice about mixing medications and alcohol.
Despite the obstacles to effective treatment---the resistance of the older person, the pessimism of the doctor, the discomfort of potential side effects, and even the danger involved---with close supervision and correct dosages, very marked improvement in mood can be achieved through medication. Do not give up to soon. With enough experimentation and careful management, depression can be relieved.
It is quite normal for people to feel anxious or fearful about many of life's events. Some deal with their anxieties more easily than others. As people age, they become more vulnerable to the threatening events of life, and at the same time their abilities to cope with these events may become less effective. Handling emotions calls for a healthy physiology and a responsive central nervous system.
When an older person who is also mentally impaired becomes anxious or frightened about events that he may or may not perceive accurately, his reactions can be extreme. The anxiety reaction of a mentally impaired older person might be expressed in agitated behavior. He might pace the floor, unable to sit quietly. He might fidget nervously, restlessly. He might constantly rummage through the house or his room or his bureau drawers, needing to be busy, using up the nervous energy created by the state of anxiety. He might wander through the house, or outside the house getting lost. He might respond irritably to whoever is near. He might shout, scream, push, spit, curse, kick or hit with objects [such as canes], all in response to what appears to be threatening.
All of these behaviors can be helped by the correct dosage of the appropriate medication, usually some form of tranquilizer. But often, as soon as the word "tranquilizer" comes up, there is a negative reaction--- another anxiety reaction, this one holding that tranquilizers turn you into a mindless zombie. As a result, many behaviors that reflect the extreme mental discomfort of an older person are tolerated without attempts to modify or treat the behavior. This failure to medicate is just as harmful as overmedicating.
When the anxiety reaction is caused by a temporary situation, such as moving to a new environment, which should clear up as an adjustment is made, minor tranquilizers are sometimes given, usually Librium or Valium. These should be prescribed for a limited period and in the lowest effective dosage, since they are potentially dangerous for older people [they can accumulate in the system and cause a dependency on the drug]. Additionally, when the older person is mentally frail, these drugs can cause further mental impairment.
When a mentally impaired older person exhibits acutely anxious behavior, the drugs of choice are usually the so-called major tranquilizers, such as Thorazine, Mellaril, Haldol, and Stelazine. If the patient is both depressed and agitated due to anxiety, Sinequan or Elavil might be prescribed.
Although all of these drugs can be effective in relieving symptoms of anxiety, they all have side effects that can cause other symptoms. And some of the symptoms may seem worse than the one that is being treated.
The most common of the side effects caused by the major tranquilizers are symptoms that are similar to those of Parkinson's disease: rigidity of the muscles, muscle weakness, and tremors that look like palsy. The older person may become uncontrollably restless. His muscles may become uncoordinated, causing facial tics and grimaces. The muscles that control the tongue and other organs of speech may be impaired and he may have difficulty speaking and swallowing. Less common but perhaps even more upsetting, he may develop spasms that stiffen his body into an arch, with only his head and feet touching the bed, or spasms that contract the neck muscles so that his head twists to one side.
In addition, he may be troubled by some of the same side effects as those triggered by antidepressant medications: dry mouth, constipation, urinary retention, nasal congestion, sleepiness, and listlessness.
All of these symptoms will stop if the medication that triggered them is discontinued. Since there is no way at present of predicting how any medication will affect a particular person, finding a helpful drug regimen is more of an art than a science---a matter of trial and error. The motto should be "Do until you get it right". It may be very frightening to see someone you love stiffen up and start to shake with tremors, or speak as though he's drunk, but these are only temporary reactions. Call the doctor for a change in medication.
Occasionally a patient who has been taking a major tranquilizer for some time develops a condition of involuntary and bizarre movements of his lips, tongue, and jaw, which does not always clear up when the medication is discontinued. It was found recently, however, that lecithin [a food substance sold in health food stores] seems to be effective in treating these upsetting movements.
Unfortunately, sometimes the original symptoms get worse with the medication and the doctors increase the dosage instead of changing the medication. You have to monitor the effects of the dosage closely and report back quickly. Remember, there are relatively few doctors who are specialized in geriatrics or the medical care of the aged, and few are interested enough in the aged to have developed the skills of psychopharmacology [the science of drug treatment of mental disorders] as these relate to the elderly. Therefore, if you become aware of some of the benefits as well as the side effects of medication and raise questions with the doctor about treating your kin's disturbed behavior with drugs, you should be able to judge whether he is interested enough to use the trial-and-error method effectively.
Sometimes, when a patient develops Parkinsonian symptoms, as described earlier, the doctor will add anti- Parkinson's drugs to the regimen rather than change the dosage of the medication. This practice should be questioned. In fact, you, the responsible relative, have a right and a duty to question, to request medications, and to refuse medication on behalf of your impaired kin. If the doctor is to authoritarian to accept your questions, you may want to search for another doctor who is more understanding.
In medicating for anxiety, another are of concern is the use of sedatives for people who cannot sleep at night. Expert opinion holds that sleeping medication, such as sedatives or hypnotics, can be very harmful for all elderly people particularly so for the mentally impaired person whose brain function may be very marginal. The effects of a nighttime sedative usually carry over into the daytime, because the drug is not excreted sufficiently in the old person. This causes an even greater level of impairment. It is considered better geriatric practice to prescribe a larger dose of an anti-anxiety medication or a major tranquilizer to be given at night to help the older person sleep without risking the sedative effects during the day.
Still another possibility to be alert to is that Thorazine type medications can worsen existing depression. If you notice that your anxious relative appears depressed after taking Thorazine, be sure to mention it to the doctor and ask if it is a side effect that should be treated.
(c) copyright 1996
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