Answers for 75 year-old mother w/ acute episode of mental decompensation
April 9, 2016 1:08 PM   Subscribe

Seeking answers for my 75 year-old mother, who had an acute and frightening episode of mental decompensation on the 11th of this month. While it has gotten a bit better, it is still present and affecting daily living.

I had seen my bright and active mother, who has easily lived alone for years, over the weekend and had left on the 9th-- she seemed to be fine at that time. Two days later, she called me in a state of panic, dread and confusion, and asked me to come back. Once I arrived, she was very distracted and confused, and most alarmingly, could not name who the president was for the longest 20 seconds of my life. She expressed feeling a paralyzing amount of dread and huge lapses in memory. She was fixated on not knowing how to get to commonly visited places. She has symptoms of agoraphobia.

Since that time, we have gone to a large numbers of appointments trying to chase down the cause and she has slowly improved to about 75% functioning on “good” days, and maybe 60% on “bad” days.

Mother is an active person who still plays tennis, and although she has always been a bit eccentric, “in her head,” and very anxiety-prone, this is a great departure from her normal. She expresses fear of the short-term future: “The days just go on and on and I feel lost and scared.” She is understandably frightened of declining physical and mental health. She expresses concerns that she cannot carry out very simple tasks that have been no problem as recently as early this month--putting a chicken breast in the oven to bake, for instance. She is ruminating on very small issues and is sometimes unable to make very small decisions. She complains that her spelling is quite poor. She has great difficulty at times understanding what I am saying. She is most frightened of not knowing how to get places.

I am going to be as concise as possible while providing all information that my be relevant:

Historical concerns:
--a history of negative thinking, anxiety, and depression treated with antidepressants, as well as untreated OCD symptoms.
--a hip replacement that seemingly went quite well 2 years ago this month
--Her mother, with whom she had a fraught relationship, died last year and she has admittedly not really grieved this, nor has she come to grips with the recent dementia of the man she has dated for 30 years. His illness has meant that she sees him much more rarely now.
--Sleep is ok, though not great. Appetite is very poor. She has a history of feeling anxiety in her stomach, with stressful times leading to both constipation and diarrhea. She is complaining of “anxiety in my stomach” to a great degree now.
--(Just in case it seems relevant) She has mouth movements of which she is unaware and have been present for maybe three years? Her mouth purses rapidly and may be in time with her thoughts and others' speech? Almost as if she is mouthing along with people. Several doctors have told me that it is NOT tardive dyskinesia, though some of the medications she has been on might cause such a symptom.

Medical findings:
--She tested positive for a UTI and was started on Bactrim. We had great hope that this was the cause and solution, but even though the UTI is cleared, she continues with anxiety and times of confusion.
--Though her blood pressure has historically been on the low side, she has had high, but within the range of normal, BP at all recent doctor’s visits.
--An MRI done last weeks shows a brain that the neurologist considers normal for her age, with no evidence of Alzheimer’s disease, stroke, or any other obvious issues.
--No evidence of thyroid or other endocrine issues. No evidence of anything deemed significant that might cause such an episode.
--Current meds:
Evista 60 mg (on it for years)
Pristiq 50 mg (on it for years)
Buspar 20 mg (also long-term)
Xanax .25 as needed (new since this event)
Trazadone 50 mgfor sleep (new since this event)

Doctors are stumped. The working theory at this time seems to be that she has had sort of an existential crisis and anxiety causing the mental confusion. She is seeing a therapist, working an anxiety workbook, and taking a low dose of BZD as needed, which she feels does not help. She is very alarmed at me leaving to go to my home, about 2 hours away, which I must do at least a couple of days every week or so. She is able to go out and visit friends, go to the tennis court and to the grocery, though she is reluctant.

I have researched the old doctor Google to no avail. Does anyone have any suggestions? Does anyone with a history of anxiety feel like this could impact thinking to this degree, where she would appear to have delirium? I am writing this now, even with the improvement, because she jut told me that she had “a carton of yoga” after lunch, and it took me repeating it twice and several moments of her in thought before she corrected it to “a carton of yogurt.” I am frustrated and quite frightened. Thank you.
posted by thebrokedown to Health & Fitness (17 answers total) 4 users marked this as a favorite
Ugh. I feel for you going through this stressful situation.

I'm a pharmacist at a hospital with a fair number of older patients, and before I even read below the fold on your question, my first thought was that she might have a UTI. Are you sure the UTI is really gone? It's really astonishing how much mental change a UTI can cause in an older person. And sometimes it is the only symptom.

Also, I wonder if her meds might be a problem. Buspar is the one that stands out to me. Yes, she's been on it for years but remember: while the drug hasn't changed, her body has. If her body's ability to clear the drug out of her system has declined over the years then a dose that was fine years ago may be too much now. If she had just started Buspar and you saw anxiety and confusion, you would definitely suspect the drug. She should consider talking to her doctor about whether the Buspar could be part of the problem. Pristiq would be the other one I might wonder about, but the first one I'd suspect would be the Buspar.

Please update -- I'm curious to see what it ends up being.
posted by selfmedicating at 2:21 PM on April 9, 2016 [9 favorites]

The husband of a woman I know whom is in his late 60s had terrible mental symptoms with a UTI that was at first undiagnosed and then resistant to treatment. He was hospitalized with what at first was thought a psychotic break of some sort. It took several rounds of antibiotics until they found the one that treated the UTI.
posted by mermayd at 4:07 PM on April 9, 2016

Thirding that a UTI can cause mental health symptoms in the elderly. Best wishes to you and your mum.
posted by Ink-stained wretch at 5:47 PM on April 9, 2016

She needs to see a neuropsychologist and get a full workup. If nothing else, this will provide a cognitive baseline against which later changes can be measured.

Also - we tend to think of our 75 year old mothers as innocent even though they too were teenagers and young adults- any chance she's got some unknown vices that have caught up with her?

A FOAF was hospitalized for a few days after accidentally eating a pot brownie from the back of the freezer - even though he knew it was a pot brownie when placed there, had forgotten about its true nature a few years later, and was very disoriented when it happened, thinking he had had a stroke. Hilarity and ER visits ensued.
posted by soylent00FF00 at 6:10 PM on April 9, 2016

Oh, this is also important and I missed it on first read:

An MRI done last weeks shows a brain that the neurologist considers normal for her age, with no evidence of Alzheimer’s disease, stroke, or any other obvious issues"

It's not possible to rule out mild or early dementia (Alzheimer's disease or other) from a MRI or other brain imaging. Only repeated neuropsychological testing can do that.
posted by soylent00FF00 at 6:14 PM on April 9, 2016 [7 favorites]

Drugs work differently in older people. The window of therapeutic efficacy is narrower, ie they can get side effects at doses that were fine e.g. three years prior; also, they're more prone to interactions than younger people.

on preview - sorry this has been covered by someone who is a pharmacist, yikes!

she has had sort of an existential crisis and anxiety causing the mental confusion.

I just think this is unlikely, anxiety whatever. Spelling? Nope. 2nd and 3rd and 4th opinions if necessary.
posted by cotton dress sock at 6:44 PM on April 9, 2016

UTIS seriously do a number on people.

I'd have her retested to make sure the UTI is clear.
posted by AlexiaSky at 8:08 PM on April 9, 2016

I can only reiterate that it might be a UTI that the pros are missing. UTIs really mess up older folks to the point where they seem to be acting crazy. I've been through it with an elderly parent of mine. It is scary.

Best wishes to you both!

I'd like to 2nd the request for a follow up comment. That could help a lot of us with elderly relatives, and it might be therapeutic for you in some way, knowing that you have complete strangers concerned about you and your mother.

Best of luck to both of you.
posted by InsertNiftyNameHere at 9:40 PM on April 9, 2016

Thanks for all the answers. We had a second white cell count and urinalysis done Thursday and haven't heard the results yet.

I can't express how acute this change appeared to be, which doesn't seem to fit with some of the other suggestions. I feel she improves a bit every day, but wishful thinking, perhaps. I will definitely report back if an answer becomes apparent. Thanks so much.
posted by thebrokedown at 6:02 AM on April 10, 2016

Late to this, but my mother had recurrent UTIs and every single time she got one, I knew just from speaking to her on the phone. And they made her paranoid, delusional, and anxiety-ridden, every time. So maybe Nth-ing this possible diagnosis isn't so helpful, but I'm just another datapoint suggesting that the etiology for all this is UTI.
posted by exlotuseater at 12:22 PM on April 10, 2016

Thanks for the update! Please let us know what they find, and please be pushy if they don't seem to be taking it seriously enough. It is very easy (even for medical professionals) to assume that dementia is just part of the territory for a older person but if this is a big change then it's a big deal. Having a family member insisting that NO this is NOT normal is hugely important.
posted by selfmedicating at 6:08 PM on April 10, 2016 [1 favorite]

Delirium is so scary to witness. I'm sorry.

Double check for the UTI or other infections. Talk to a neuropsychiatrist about meds. A family member of mine had meds-related delirium. We learned that he cannot take any kind of sedative without triggering an episode. Some of the new meds she's on might be making the situation worse or prolonging it, even if it was originally triggered by the UTI. My family member's delirium was originally triggered by an infection, but meds prescribed during treatment in the hospital made it linger for months. It wasn't until he was weaned off the meds, under the supervision of a neuropsychiatrist, that he recovered.

And make sure you know any OTC meds she might take (OTC sleep aids, Benadryl, alcohol?)
posted by snowmentality at 6:15 PM on April 10, 2016 [1 favorite]

Additionally -- my family member's delirium was primarily characterized by extreme anxiety and paranoia. Sedatives trigger it, but with a completely paradoxical effect -- they make him agitated and scared. His doctors kept trying to add more sedatives to calm him down, but it only made it worse. I say this because your mom's anxiety symptoms might be related to the delirium, even with her history of anxiety.
posted by snowmentality at 6:31 PM on April 10, 2016 [1 favorite]

To add on to what snow mentality is saying, benzos are not preferred in the elderly for numerous reasons. Especially if she doesn't feel that the Xanax was helping, stopping that could be a good idea even though it seems paradoxical to stop an anxiolytic when she is acting anxious.

A couple of things to know, in general, about elderly people:

- Their systems are quite fragile in some ways, and treatments can end up causing what started as a small problem to spiral. This is why geriatricians often push for NOT starting treatments or reducing numbers of medications whenever possible. Common examples that might be helpful: antibiotics for a respiratory infection or UTI turn into horrible, antibiotic-associated diarrhea called C diff and end up as life threatening. A person who had very mild cognitive impairment comes into the hospital, away from everything that was familiar to them, and suddenly seems far more cognitively impaired than they did before, and gets agitated, requiring sedation and restraints. In this case it's possible that a UTI could have produced mental health symptoms that resulted in her getting put on new psychiatric medications which may have ended up impeding cognitive recovery. But there are other possibilities too.

- Episodes like this can happen "idiopathically" (meaning we don't know why). It is pretty frustrating as a clinician, but many times I've had a patient come in with symptoms like your mom's and done a million dollar workup for altered mental status, found nothing, admitted them to the hospital, and they got better in a few days and went home without us ever finding anything else wrong with them.

- Depression in the elderly can look similar to mild dementia. Check out this little quick reference for details.

- If the symptoms continue to improve then it certainly may all just be related to a spiral from a UTI. If not, a neuropsychiatrist could be useful.
posted by treehorn+bunny at 12:36 AM on April 11, 2016

Have her meds changed from brand name to generic or vice versa recently? Has the manufacturer for generic meds changed recently? Just a couple of other things to think about.
posted by brevator at 4:43 PM on April 11, 2016

If it turns out to be a UTI, here's a tip for the future. We were told this by a doctor who was treating a family member -- with elderly patients, especially women since they're more prone to UTIs, he suggests they take Vitamin C supplements all the time, because it makes their urine more acid and therefore a less-hospitable environment for bacteria.
posted by LobsterMitten at 9:30 PM on April 11, 2016

This reminds me a lot of what was happening with my mom a few years ago. The dramatic difference in ability to function, the fear, and particularly the mouth movement thing. We spent the a lot of time with a number of neurologists before they ultimately decided on a diagnosis of progressive supranuclear palsy. In her early stages, my mom's behavior and mental changes matched a variety of things - it was only after about a year of her symptoms progressing that things became clear.

Good luck - this is tough stuff to deal with. Your mom is lucky to have you looking out for her.
posted by Orrorin at 9:46 AM on April 19, 2016

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