May Cause Hallucinations in the Elderly

Actually, that was the best piece of news in what had been a very very long day. Now there was some hope again. But I'm way ahead of myself.

It started with tucking Daddy in bed as usual, but with him waking up again just after I went to bed. He was already itching again. I applied lotion (having just bought another 6 tubes of Lanacane) to the spots and went to bed. Too early to add a 2nd Atavan to put him back to sleep. A couple hours later, he was calling again. More lotion. This time I literally had not pulled the covers back up to my chin when...

"Heather!"

"What do you need, Daddy?"

"I found a couple more spots."

Sigh! "OK, show me where they are."

"They're up there," he said as he pointed at the ceiling. "But we don't want to eat the ceiling, do we?"

After assuring him that we were not going to eat the ceiling and tucking him in, now adding another Atavan to try to get him back to sleep, I returned to bed. This time he was mumbling away, talking to people who weren't there (mostly due to their deaths years ago) about things that weren't happening. It's one of the joys of being on the other end of a baby monitor, listening in on things like that, trying to sleep, trying to decipher what needs attention and what doesn't. Silence eventually descended, and then...

Crash!

"Damn! ...Heather!"

I was already on the way, finding him on the floor next to the bed. He was trying to do something with the phone, tangled up in his walker and his tubing, trying to get up, trying to make sense of his world. I pulled the walker out of the mix, determined that he was not hurt beyond a scrape needing a bandage, and asked him to please sit still a minute so I could go and get help. I woke Paul, who was able to get him back into his bed. Daddy informed me he was trying to go back in the corner to get his bicycle.

As if.

After settling him in, asking him to promise me he'd stay in bed, I returned to my room. He was immediately holding conversations again, and about twenty minutes later called me back to his room. This time he needed me to hang up his needle for him. He was finished sewing and the shelf that had been hanging directly over his bed had somehow disappeared.

On it went. Shortly after I heard Paul leave for work, there was another crash. This time he was on his floor, leaning in the hollow between his armoire and his laundry hamper. He'd scraped his same arm down the rough edge of the front of the hamper, and was bleeding more than after the first fall. I determined he was not all that seriously injured, asked him to again sit still so I could think about what to do - right then sleep deprivation was interfering with my decision making abilities - and went and called Richard. This time it took both of us to get him back into his bed. I left him sitting so I could clean up the blood, both on him and not, and give him another bandage.

It was time for another dose of lotion, which I applied while Richard made coffee. May as well give up trying to sleep now. We didn't need another fall. Let's get him out into his chair, feed him coffee, and maybe help him get lucid enough to cope with his day. He couldn't even give a reason this time why he'd gotten out of bed.

After one sip of coffee, he promptly fell back into sleep, or at least what passses for sleep for him these days. He spends a lot of time in this state where he isn't asleep but isn't awake. It's like dreaming, but lacks the paralysis of REM sleep. He can talk, he can go through the motions of whatever he thinks he's doing. And, we found out, he can fall. For right now, though, it appeared to be genuine sleep.

I knew I was in no shape to drive, so I called work and let them know I'd not be coming in. Then I called Randy.

I'd been trying to hold it together, with various degrees of success, through the night. I tried hard not to burst into tears at the first sound of her voice. "Help!"

She was great at helping me sort through events and figure out what was important and what needed attention, and why. Suddenly I wasn't helpless. Some things could be done. He needed to be seen, either at the urgent care/ER or his doctor's office. Was it a medication reaction? One of several other possible causes? Suddenly there was a list of questions, answers to be found.

I couldn't conceive of getting him into the car and driving him down to Maplewood, so it was going to be the hospital. And as I thought more about it, it would be an ambulance ride. He had almost fallen on the way from bed to chair - three times! His balance was terrible, his strength virtually nonexistent, cognition still impaired, and the walk was icy from the night before. Strike that, it was still coming down freezing sleet. He needed professional transport, with a gurney, oxygen, and lots of extra muscle.

Rich and I took turns staying with him while the other dressed, prepared a cleared path to the house, showered, fixed and fed him breakfast. Once we knew we were ready, I made the call, the living room became crowded, Rich climbed in the ambulance with all his medications for the ride, and I got in the car, now warm and sufficiently deiced after running for over 20 minutes. Daddy'd actually become fully alert with all the attention from the First Responders. It's the kind of thing that makes you wonder if they're scratching their heads and asking themselves just what the heck these people were complaining about? (Just like the hyperactive child is fascinated and quiet in the doctor's office and the parent gets pegged as an incompetent whiner.)

In the ER he became himself - the most recent version that had us so worried - again. After lots more bustle, vitals being taken and sensors getting dislodged, blood being drawn and tested, questions asked, answered, and asked again with the shift change, it was time to try to make some decisions. Should he be admitted? Would it be possible to keep him both safe and comfortable at home? Should he be sent to a nursing home? Could they even keep him safe if he was determined to wander in the night? Would there be a high enough staffing level to do the checks necessary?

At one point I had Randy on my cell phone talking with his doctor, sharing information, opinions, suggestions. We all came to a resolution. The best place was still home for him, if there were a way to keep him asleep and tranquil through the night. If he still wasn't all that lucid during the day, we could cope. During those times he was lucid, he'd be much more comfortable at home, in familiar surroundings, knowing he was being cared for by family, not abandoned by them. If and when we decided to fully switch him over to hospice, the paperwork was handled and could be done quickly.

When the labs came back, we had the last bits of information we needed to make our decisions - for now, anyway. Everything showed deterioration in his condition, but it was all chronic, not acute, and nothing that really justified admitting him for treatment. There would, however, be two medication changes made, hopefully ones that would settle him for the night. Likely what was waking him was pain, whether he could communicate that to us properly or not. Since we didn't really know that he could tolerate morphine, the doctor prescribed Dilaudid, or hydromorphone in the cheap version. This ought to keep the painful itching from waking him. It would also work well with the Atavan, which was being increased to a full mg. instead of a .5 mg. dose.

Randy would get us a bed alarm for him as soon as possible, so we'd be warned if he moved. Both times he'd gotten up, the effort paradoxically had quieted him so there was no warning. Everyone agreed that there was no safe and humane way to keep him restrained in bed. We'd hope the combination of drugs and the alarm would work.

Now to get him home! I had to run home for clothes. He'd been transported in pajamas, stocking feet, no jacket, no home oxygen. I was still highly doubtful that he could walk from the car to the house, especially with ice continuing to build while we were inside, and we still had no wheelchair for him (another thing Randy is working on). The hospital social worker contacted the local transport system for nursing home patients, one that actually provides wheelchairs with the ride. They could be there at 2:30, and cost a mere $26.

Another problem solved.

Rich would stay with him and keep him calm, providing directions home, helping get him dressed, hooking him back into the home systems when he arrived. I'd head back out to the pharmacy and get the new scrips filled.

When I got back home, one of his home health aids was working with him. His other one called to find out how he was doing. During the conversation, I'd reminded her of the bizarre behaviors she'd witnessed yesterday when it was her turn. She casually asked if we had him on Benadryl? She'd gone to a medications seminar and learned that it can cause hallucinations in the elderly. It's often given as a sleep aid. She'd actually seen the results in person before, and they were much like what Daddy was dealing with.

Eureka!

Guess what he was taking? Generically, of course. And it had just been added back in to his stack of meds to help him sleep - we thought. It worked with the other meds, and could also decrease itching if there were a histamine component to what was going on. Nice theory. Unfortunately, the elderly can react to it in the opposite fashion.

I thanked her profusely, removed it from his pills dispenser, relabeled the bottle with the cautionary note, and removed it to a different part of the bathroom. We could still use it, after all. Unfortunately, we'll have to wait for it to wear off. One of the things the doctor tried for his itching while he was still in the ER was - Benadryl! Via his IV.

Oops.

Oh well, his life continues to be filled with things and people that aren't, but now we have hope that lucidity can return, and fairly quickly. He ought to be able to make sense of whatever time he has left, and his test results suggest it could be fairly short.

Oh yeah, and maybe I can sleep. What a lovely X-mas present!