How to handle behavioral issues?

See the article on geriatric psychiatrists here, on Aging Care

BY DR. HELEN KALES
I am a geriatric psychiatrist. Um, what is that? An older psychiatrist who is ready to be put out to pasture? Nope. A psychiatrist that has an extra comfy couch so that older patients can lie down and tell me about their mother? Also, nope (although I do enjoy comfortable furniture).
A geriatric psychiatrist is a medical doctor (four years of medical school after college) with four years of general psychiatry training (an internship/residency following med school) and an extra one to two years of sub-specialty training (a geriatric psychiatry fellowship).

A psychologist cannot prescribe medications, but an M.D. psychiatrist does.
In psychiatry, the M.D. furthers the degrees and area of study into specialties.
In neurology, an M. D. can then specialize in psychiatry, adding geriatrics.
A geriatric psychiatrist specializes in elderly, and has accreditations.
Any psychiatrist can then specialize in elderly patients, but it is a matter of furthering their studies, obtaining specialty degrees, associations, and certificates to become accredited in the field of geriatrics, or gerontology.
Neuropsychiatrists specializes in study and treatment of the brain biochemistry.

What is Neuropsychology?
Clinical neuropsychology is a sub-specialty of clinical psychology that specializes in the assessment and treatment of patients with brain injury or disease. A clinical neuropsychologist usually holds an advanced degree in clinical psychology (Ph.D., Psy.D.), and has completed a clinical internship and specialized post-doctoral training in clinical neuropsychology. What distinguishes a clinical neuropsychologist from other clinical psychologists is knowledge of the brain, including an understanding of areas such as neuroanatomy and neurological disease. The discipline involves the application of standardized measures in the study of brain behavior relationships. They use neuropsychological tests to assess cognitive deficits, and they are involved in the management, treatment and rehabilitation of cognitively impaired patients. Neuropsychology also entails the development of models and methods for understanding normal and abnormal brain function.

A geriatric psychiatrist precribes medications for the sort of behavioral problems you describe. It sounds as though she is suffering from agitation and possibly depression. There are chemical changes that occur within the brain with dementia that sometimes cause these. Meds can help, and not in a way that cause your loved one to be "drugged".

As Rainmom points out, meds helped her mom become calmer. I saw this with my mom as well.

My mother has seen a neuropsychologist for testing. I have seen that people are recommending a geriatric psychiatrist, but I'm not sure what for, could someone explain it to me? I appreciate your remarks, Rainmom. My mother is in her late 80s, we are in our mid-fifties. I can tell you that in HER mid-fifties, my mother was having a ball dancing and singing, not taking of anybody. My husband and I are not retired, but we work different shifts (and I work 30 hours a week), so, except for a few hours on a couple of days a week, one or both of us is always here.

There are many good points made above. I'm including a link for an article on this site about how dementia behavior may seem like manipulation, but it's not.

I think many caregivers struggle with this. It's so tempting to assign some kind of blame. When the stress is too much and it's just very overwhelming, I would look for assistance. Trying to punish or blame is not really appropriate with a dementia patient. It won't get you anywhere and the person will not benefit from it, either. It is likely to just make them feel more confused, agitated and frightened.

Have you explored what options are available for her care? I might read A LOT about dementia and what you can expect down the road, because the behavior and challenges are likely to increase substantially. Having a plan is one thing the article recommends.

https://www.agingcare.com/articles/dementia-behavior-manipulation-154554.htm

It is really nice that your husband does make time to pay social attention to your mother. That is hugely beneficial to her, and a Good Deed on his part, and takes a little pressure off you.

However. It sounds as if he is still thinking, or maybe just hoping, that normal thinking processes - such as a grasp of logical consequences - apply. You both need to abandon that idea for good. They don't. If they haven't already completely gone, they soon will; and it is certainly futile and potentially cruel to continue to hold your mother to standards of behaviour that she cannot possibly keep in mind.

The rages that first led you to post... Those must be incredibly hard on you, and painful. I'm really sorry you're having to witness them, let alone be the target. Teepa Snow's videos might be helpful and comforting, and offer some guidance about detaching from the emotional hurt. The better behaviour you see at your sister's house, or during activities, I would guess is actually more to do with the pleasant stimulation of those environments rather than a control issue as such - again, I think it's probably attributing too much to your mother's remaining reasoning ability to suppose that her frustration and irrational anger comes from trying to be in control. Although, yes, I'd agree that it would be frustrating to her if domestic routines that should be second nature have become bafflingly difficult. For guidance on helping her to do things without triggering her frustration, there's another thread started by a lady whose husband is beginning to struggle and getting angry about it - can anyone remember the headline, please?

Please don't stop her enjoying anything she is still able to enjoy. Depriving her of these pleasures will not restore her reasoning faculties. It'll just deprive her of her dwindling opportunities to have fun.

I'm sorry to say this, but the real trouble is that it is only going to get worse and whatever you do is not going to arrest your mother's decline or mitigate the challenges of it in anything more than the very short term. So, it is time to consider options, collate information about costs, resources and her likely future care needs, and draw up a plan. Do you have POA? If not, it sounds as if you might have missed the boat there and could need to apply for guardianship, especially if your mother is unlikely to be co-operative. Ask around friends and your mother's GP, and if anyone can reliably recommend an elder care specialist it would be a good idea to take legal advice.

Army retired makes a good point. The earlier in this disease mom moves to AL, the easier the adjustment will be.

Have you thought about selling her home and using the proceeds to pay for an assisted living facility? You have only started being 24/7 caregivers and already serious issues have come up. You also need to make time for you and your husband together.

I wanted to expand a bit on my suggestion of a geriatric psychitrist. I don't mean in a lie down on a couch and reply to "and how does that make you feel?" kind of way. My mother saw one once - it was a long-ish appointment. He also spent a bit of time talking with me. My mom had been on an antidepressant for a long time and had recently begun Ativan for agitated meltdowns. Plus mom was on a couple other medically related rx's. Anyhow - the psych revamped her meds and over the next month mom started some, stopped others - all done gradually. By the end of the month my mother was more clear thinking and more pleasant to be around than she had been in years. And absolutly no zombie effect. Again, I can't recomend seeing a geriatric psychitrist enough for anyone who is having behavioral and/or temperament issues with a loved one suffering with dementia.

katannsad, what everyone has written is good. About letting her continue to go out -- Going out can help them stay oriented if it is what they have always done. It gives your mother a chance to feel normal and be around people. Soon enough there will come a time when she can't do these things anymore. I would let her do them as long as you can. If your mother is anything like mine, staying involved in familiar activities helps her feel upbeat. It gives her something to talk about and to look forward to.

My mother gets most disoriented when she is around people who make her nervous. She pulls inside herself and gets absolutely confused.

Your mother may be doing something we call showtiming for your sister. When someone is around someone they don't see every day, they can act like everything is normal for a while. It is why someone with dementia can fool their neighbors and doctors. It does seem to take some energy to showtime, though. When they get home, they are tired and seem even worse than before for a short time.

About doing the nail cleaning at the sink -- Humor can go a long way. Goodness, Mom, who raised you? Wolves? Go to the bathroom and do it. Keeping it light keeps it from turning into an argument.

Your husband sounds like a jewel, but you'll have to let him know that denying her activities won't teach her anything. It may just make her become disoriented and anxious. This happens with my mother if we have to miss church and going out to eat on Sundays. She orients her life to Sundays. It would be really hard on her if I stopped taking her to church and to eat. Keep doing anything she enjoys or let someone you know do it with her.

Your right, your husband is not a jerk. Probably just frustrated with the "up in the air" aspect your lives have taken on. And if he's anything like my husband, he's probably not happy seeing what this is doing to you and how hurtful your moms words can be. Perhaps he's grasping at solutions - trying to use reason in a situation that is unreasonable. When I think back - before I had a better understanding of dementia - all the wasted hours and the frustration trying to get my mother to be reasonable - to see clear and basic facts. It was hard because my mom had been such an exceptional smart woman. So, you've got a rough road ahead and you can't put your own lives on hold forever - as you well know. If it's possible, try to get your mom into see a geriatric psychitrist. It was the single smartest move I made and it made a world of difference. I only wish I had known to do it years ago!

How old is your mother? how old are the two of you? You say you have a place of your own to deal with, this is difficult. Would you be better off if she moved back with you? Are you on FMLA or retired? Lots of question here I know... My hubs is the stay at home guy.. I still work. It works for us but maybe your hubs is not good at the day to day. You can;t "punish" her, she won;t get it for more than 5 minutes. Any maybe you both need to think about what comes next.. because it won't be pretty. Good luck!

Have her tested for a uti if there has been a sudden behavioral change.

Has she been seen by a geriatric psychiatrist?

Dementia is a disease that destroys reasoning skills, not just memory. Your mom's perception of what is "better" may or may not be accurate.

OK. This I think is part of my husband's reasoning. Occasionally we send her to my sister for respite care and it's noticeable that she behaves better; she has even noticed it herself: She literally said: "It's easier to be in a place where I don't have to have control." I think it is REALLY difficult for my mother to have us take over the running of the house. There is a struggle for control there that makes us ALL unhappy, not least herself. She's happier on the occasions where she doesn't know where she is and thinks she's our guest, which does happen occasionally. So I think his idea is to take away some routines from her pre-dementia life, not to strip her of dignity.

I think that my husband's ideas of setting limits is not going to work because she cannot really learn anything new. However: he feeds her, bathes her, and is playful with her in ways that I simply cannot be. We take her to concerts, to the movies, and to restaurants. So he's actually not a jerk.

And yeah, it's getting to us. It's finances. Getting her adequate help is proving very difficult. We have now been staying with her for several months now, after her doctor said she could no longer live alone. We aren't sure what do with our place, her place, anything. I am trying to apply for aid from the VA; everything is in flux, everything takes forever. And yes, I've heard of sundowning. And I've spoken with an elder law attorney, social workers. I've joined a support group. And we started her on meds for anxiety a month ago. I thought it was helping, but the last few days have just been bad.

Kat, no one can successful punish a person who has dementia. That person won't remember it a half hour later, if not sooner.

Time for your hubby to read up on Alzheimer's/Dementia. Scroll to the bottom of this page to the blue section... click on ALZHEIMER's CARE... now scroll to the articles and have him read, read, read. If one is armed with as much knowledge they can get on the subject, the better understanding what is going on.

My Dad just started with dementia and the sundowning, and I know it isn't easy to get use to. I found if my Dad's mind is off in the weeds somewhere, I can bring it back for a while talking about "weather" as he is still up to date with weather national wide.

Can you just feed her something about 3:00 p.m. to 4:00 p.m.? Maybe she can no longer wait for dinner. Remember hor's Douvres? Little quiche, bite sized.
A snack portion of applesauce? A snack of jello, a little medication, and t.v. distraction in the hours prior to dinner?
A popscicle, lemon to prepare her palate, ha ha, said to make you laugh.
Just give her a pop-tart then.
One cannot always determine why, or the motivation. But please try feeding her early, put her to bed early if you must punish someone.

Babalou - 1, 2, 5? Lol - just teasing you!

Kat, I'm going to question a couple of your assumptions.

1. What reading have you and your husband done about dementia? Has someone told you that your mom has only a short time to live? Lots of posters on this board have parents who've had full blown dementia for more than ten years. That's a long haul to my way of thinking.

2. Have you ever heard of sundowning? The fact that your mom exhibits agitated behavior late in the afternoon suggests that to me. Talk to her doctor about this agitation. Meds can sometimes work wonders.

3. How long do you plan on staying at her house? Are you keeping your house? Since this is most likely not a short term project, you might want to rethink some of your plans.

4. I'm glad that your mom can keep going to some activities. I doubt it's making her feel like she's in charge. But it suggests to me that 1. Your husband doesnt understand dementia and 2. He's wearing thin ( i would be too; the world should not revolve around your mom).

5. It feels to me like it's time to rethink, assess mom's living situation and assets and figure out where she should be cared for, and by whom.

Okay - to be honest your husband sound like he's a bit of a jerk. Sorry. But really? Punishing an elderly woman for things she does because her brain is dying? You'll get no better response than you would from diciplining a two year old. It's sounds like you already know this. I admit when my mom really gets under my skin I think "she's doing that on purpose"! But once I've calmed down I know that not to be true. And really, what's wrong with your mom doing things that still make her feel competent? Or would your husband rather she be striped of any shreds of remaining dignity she might have?

Sorry, one more thing: my mother has regular tickets with me and a friend of hers for one theater group, tickets with a friend to another theater group, and a monthly meeting with friends to play word games that I now have to accompany her to. My husband feels like these kind of activities (a continuation of activities started pre-dementia) make her still feel like she is in charge or competent and are contributing to her behavior -- which much of the time you can tell are crazy attempts to somehow re-assert herself. It has not helped matters that my husband and I have had to move into HER house to take care of her and try to come up with solutions, as our place is too small to have her with us. Anyway, do you think his opinion has merit? He is not opposed to taking her out on occasion, etc., he just thinks that continuing these three regular activities are making her behavior more difficult. I really don't know. What do you think?