Yesterday I made an initial home visit to Judith. Prior to the visit two daughters told the story about episodes of aggressive behavior during which she would accuse her caregivers of trying to kill her and actually leave the apartment and be found in the lobby. This was not her usual self. Her caregiver and daughter agreed that this occurred in a regular pattern of good and bad times of the day. There were also periods of tearfulness and statements like, "Why do they tell me I have dementia and then they don't do anything about it?" and, "I don't want to go live in a nursing home." Judith's husband lived his last years in a nursing home because of dementia. Judith earned a master's degree in education over 70 years ago. A black woman didn't get that far in those days without fortitude and determination.
Initially she told me that her memory was not too good and, "What you do you expect at my age?" She told me several times that her vision was "smoky," as if this was coming and going while we were talking at her dining room table. When the family described the episodes of paranoia, she became upset and accused them of making things up about her and demanded that she be included in the conversation.
Three months earlier her primary care physician had prescribed Ambien. This is the drug that is well known for causing people to do strange things in their sleep and not remember the goings-on. Specifically, in the fine print package insert it says, "decreased inhibition, extroversion which seems out of character, bizarre behavior and hallucinations." A younger person would figure out that their behavior as described by others was drug induced and not attribute it to a brain disease. Judith's prescription pills were being given to her as part of an official plan of care. She wasn't taking them at will or even particularly paying attention to her medications. Her family started to treat her like she flew over the coo coo's nest, which was reminiscent of their father's dementia symptoms, and she started to believe it too, expressed as crying and negotiating. And she fought it by advocating and asking for help. When Google lists four million hits for side effects of Ambien, many women with a master's degree will get the message. When the pharmaceutical package insert says the data for metabolism in the geriatric population includes 187 people over 60 years of age, none of those people are 97 years of age and they won't be able to read the fine print either.