Alzheimer's, Dementia, and Parkinson's Disease

Is it possible she is talking in her sleep? Talk to her doctor about medication adjustments. I would consider changing only one medication at a time. Trazodone can often be used at 50 to 100 mg dose at night (even higher if helpful). Seroquel can often be increased to 50 or 75 mg at night. If that is not working, her doctor could consider very low dose 0.25 mg lorazepam. Other choices might include zolpidem or gabapentin. Galantamine is not known to cause sleep issues, but it would not typically get rid of them either.  

Since I do not know your mother very well, this may be hard. Many times they will adapt very well after a honeymoon adjustment period. However, I would consider telling her that TEMPORARILY she will be staying at a new place where they will be providing activity therapy to help with her brain, that you will be coming to check in on her frequently and that you will be getting assessments of how the therapy is going. It may be helpful to ask her doctor if he/she would also recommend this place to your mother as a place than can help with her brain condition.  

If he has cognitive changes and cannot perform his usual activities of daily living because of thinking problems, then he fits criteria for dementia. He may have vascular or stroke related dementia given his medical history. Parkinsonism, or tremors, stiffness and slowness, can be due to strokes. Parkinson’s disease and dementia with Lewy bodies are distinct neurodegenerative conditions that can also cause these same clinical features. His sleep disturbance may be related to REM sleep behavior disorder, often but not only seen in dementia with Lewy bodies. Parkinsonian conditions also often disrupt the circadian rhythm (sleep and wake cycles). Both nortriptyline and Ambien can cause confusion at times. Ramelteon (Rozerem) 8 mg nightly often helps the circadian sleep wake cycle dysfunction common in those with PDD. Over the counter melatonin is another choice. Trazodone nightly can safely be used for sleep issues. Seroquel at night might help both with sleep and hallucinations. If you wish further information regarding the best behavioral treatments for these conditions, you may wish to purchase my book, "Long-Term Management of Dementia" (Informa Press) through Amazon or click on the icon next to my picture.  

It is hard to answer your question without knowing more about the conditions they have. There are also possibly personality traits that are coming into play as well. Perhaps there are limits that can be placed on calls by the LLC from your mother to your grandmother. 

Hopefully you took her to the emergency room right away. These symptoms could be a sign of a stroke. If it is a stroke, every minute you delay getting to the ER typically means more loss of brain function. If a stroke is ruled out than other causes can be evaluated including stress issues. 

Parkinson’s disease dementia (PDD) patients can develop agitation and sleep issues. It is common to give medication trials to see if he responds. Ramelteon (Rozerem) 8 mg nightly often helps the circadian sleep wake cycle dysfunction common in those with PDD. Over the counter melatonin is another choice. Trazodone nightly can safely be used for sleep issues. Seroquel at night might help both with sleep and agitation due to false beliefs. If you wish further information regarding the best behavioral treatments for these conditions, you may wish to purchase my book, "Long-Term Management of Dementia" (Informa Press) through Amazon or click on the icon next to my picture.  

He has physical problems, but it is unclear to me how severe his cognitive issues are. If his dementia is to the point that he is no longer able to make appropriate decisions, then if he has a Durable Power of Attorney (DPOA) for health care and finances set up, it should be put into effect and that individual(s) can decide for him and have someone stay the night or have him move to a facility. If he does not have a DPOA and is significantly demented, a guardian appointed by the court is the next step. Another way to approach his reluctance is to bargain with him and suggest that just temporarily, as a trial, for a week or two, you are having someone stay overnight. Tell him it is mostly for your own peace of mind and that it is affecting your health (if it is) because of worrying about him so much. After the trial period, you can reassess and maybe extend it temporarily if things are working out. 

I am not sure what type of spasm you are describing. Myoclonic jerks are quick, can be one side or whole body and may affect the jaw of mouth. They can occur frequently. These are best treated with divalproex sodium (Depakote). Muscle cramps, like a Charley horse can be related to electrolyte imbalances. Try tonic water or pedialyte like drink. Rarely, tetanus can occur from a wound infection and lead to facial and body spasms. 

Depression is a common disorder in those with Parkinson’s disease. It is caused from environmental situations, but is contributed by her brain dysfunction from the areas damaged in those with Parkinson’s disease. Increase pleasurable activities for her and talk to her physician to see if an antidepressant is suggested. 

 She has issues with judgment and probably insight. If she is also having problems with memory, language, sense of direction, problem solving or performing activities of daily living, she is developing dementia. She needs to be evaluated by her physician to find the potential reasons and to get appropriate treatment to prevent further cognitive loss. The sooner, the better. Have her physician give her the SAGE test, a self-administered cognitive assessment tool. This is an excellent screening examination that can be downloaded free from the web at http://www.sagetest.osu.edu

I would follow the advice of the cardiologist who knows your father’s medical condition the best. 

The solutions to these questions would depend on the reason she is refusing care and nutrition. Sometimes when individuals get that old, they have decided they have lived long enough and wish to die. They may not tell loved ones their true intent for reasons of their own. Others that old may develop dementia and not understand the need for nutrition or care. In some cases, their organs are just shutting down after 100 years. In others, there may be some underlying depression or a mix of a lot of things. The goal at that stage is to provide quality of life and not force individuals to have to follow all the “rules.” 

Even if your mother in law has a dementia condition, from your description, she is safe and well taken care of at your house. You have family that care of her and know her and so your home would be a great place for her to be. Anyone can fall, even if you are standing right next to them and try to prevent a fall. There is no reason you would need to place her into a nursing home unless Adult Protective Services (APS) for some reason felt she was not safe or well cared for at your home. You could ask APS to come to your home so they could verify that the home setting is appropriate. If your mother-in-law has the capacity to make decisions, she can designate a person as her Durable Power of Attorney (DPOA) for health care who would then be her surrogate to make decisions for her if she were no longer able to make decisions on her own. You can consider contacting the local chapter of the Alzheimer's Association to help you understand more about a DPOA. Other agencies or a lawyer skilled in elder law could be considered as well. Her dementia condition could be further evaluated with cognitive screening tests like the Self-Administered Gerocognitive Examination (SAGE), that is best taken at her doctor's office but that is also available on line at http://www.sagetest.osu.edu. 

Driving issues are difficult for many. It is to your advantage that the eye doctor is willing to "be the bad guy" and tell him that it is now unsafe for him to drive. In this way you can say that it is not you but the doctors that are telling him not to drive. He will likely counter that he can see well enough to drive. In those cases, it may be wise for the doctor to refer him to a professional driver evaluation test or to his local motor vehicle department for paper and behind-the-wheel testing. If his cognitive issues are getting worse, it is likely he will fail those tests. Another technique may be to tell him that temporarily he needs to stop driving while x, y or z is being evaluated or because he is starting on a new therapy, if true. It is always easier to be accepting of something that is "temporary" rather than something permanent and stopping driving forever. Periodically, he could be re-evaluated and the doctor can declare that he still needs to temporarily hold off on the driving.  

High blood pressure can be a cause of headaches. High blood pressure can also cause strokes. However, if she had an MRI scan of her brain, strokes are very easily found, even if they are very small. If she had an MRI scan of her brain and no stroke was found, then she did not have a stroke. A CT of her head may not reveal small strokes. When strokes cause language deficits, they are usually very obvious to everyone and would not fluctuate with good and bad days. The person may not be able to comprehend well or may not be able to get words out well. Strokes affecting speech would cause slurred or strained speech patterns, which also would not fluctuate. Acting childish and having tantrums are not typically stroke behaviors. Perhaps she is afraid of you not being around. You can offer her ways to contact the emergency squad to take her to the hospital if you are not around (button around her neck to push, phone to call 911, etc). You can arrange for companions to come in to be with her while you are away. Senior centers or day care centers can be used to care for her during the day. Depression and anxiety symptoms, if present, can be treated with antidepressant medications. You need to sit down and tell her that you will be gong to college but that you can help arrange for her to be safe and protected while you are away.  

Head trauma with bleeding in the brain might cause confusion, depending on the degree and placement of the trauma and bleeding. Changes in environment such as being in a hospital can, in and by itself, cause confusion. Parkinson's medications can cause confusion and false beliefs. Any new medication could be a cause. Infections, like a urinary tract infection, are frequent causes of confusion. Her physicians can run some tests to determine if there are alternate causes for her confusion. During her confusional state, make sure she is very well supervised to prevent more falls or injuries.  

It would be hard to determine with such little information. Medications can cause unusual movements. Is she taking any new medications? Diabetes can cause renal disease in some cases. Chronic kidney disease can lead to abnormal movements. Restless leg syndrome is a condition where the person feels the need to move their legs as they feel uncomfortable. Sometimes that is due to low iron. There are treatments available. Her doctor may be able to evaluate for other potential causes.  

It may be difficult to convince your brother unless he experiences the same behaviors. However, you are correct that there are many causes of screaming and cursing that are not related to pain in severe dementia patients. Sometimes they just want to be left alone. They may feel threatened. They may think they will be hurt. The approach to your father will be most important in his behaviors. Distracting him with soft objects to hold, playing his favorite music, or adjusting the environment may help. If his screaming behaviors are occurring at other times than with care issues, behavioral medications may be useful.  

Quetiapine (Seroquel) can often be helpful for the false beliefs, suspiciousness and visual hallucinations often seen with those with dementia with Lewy bodies (DLB). Very low doses (25 to 75 mg daily) are typically helpful. Seroquel can have side effects; the most common one is sleepiness. If she has clear side effects from the Seroquel, perhaps a lower dose would have less side effects. There are other medications in the same class of medication that could be tried if she has false beliefs, suspiciousness and/or visual hallucinations. Instead of Seroquel, ziprasidone (Geodon) may be tried (20 to 60 mg daily). In regards to communication issues with her doctor, you might try writing down your questions. You can ask if the doctor has a nurse practitioner or physician's assistant or nurse or social worker that you could talk to. They could summarize your questions and present to her doctor. Going to support groups like with the Alzheimer's Association or the Lewy Body Dementia Association may help provide you answers to questions and suggest improved ways to communicate with her doctor.
 

If he has memory or cognitive issues in addition to his motor issues, then dementia with Lewy bodies is possible. They typically do not have much in the way of tremors and often can have visual hallucinations. Most of these patients typically perform better when others are around. They tend to sleep more and more or keep their eyes closed more often. Carbidopa/levodopa and other anti-Parkinson's disease medications can also cause excessive restlessness and hallucinations. His physician could consider that these be tapered down if he is on them.  

His passing out spell seems to more likely than not be related to his dehydration and diarrhea, perhaps causing his blood pressure to be too low. Review of medications and checking for infections are reasonable to look for causes of his diarrhea. I am not an expert on gastrointestinal problems. However, if he is on anti-dementia agents like donepezil or rivastigmine, or glantamine, they could be cause of his diarrhea. I would hold those medications as well. The Exelon patch has the least diarrhea potential of those anti-dementia agents. Drinking too many nutritional products (Ensure, Boost, Health Shakes, others) may cause diarrhea. Sometimes I have had luck with using probiotics over-the-counter to help with diarrhea. Also fiber may be useful.  

It is hard to understand his condition given the limited information. It sounds like he has dementia, behavioral changes, and movement abnormalities. Some movement issues can be related to medication use. Normal pressure hydrocephalus can cause gait and urine and thinking problems. Strokes, Parkinsonism, and other dementia conditions are all possible. A good diagnosis from a work-up that would include a brain scan, lab tests and cognitive assessments may suggest treatments that could be useful.

 

These false beliefs are very common in many dementia conditions. They are usually easy to treat with low doses of antipsychotics. Dementia conditions like Alzheimer's disease will present with significant memory deficits. Parkinsonism can be related to small strokes in the brain or may be due to a condition called dementia with lewy bodies. They tend to have more visual hallucinations. Voice tremors are usually caused by other conditions than Parkinson's disease and can occur with hand tremors. I would suggest your grandmother to see a neurologist who specializes in cognitive issues. Mental status testing can document if a dementia condition is present. Further work-up as required will help with diagnosis and then appropriate treatment and management can be applied.

 

If her behavioral issues were better controlled, life for all caretakers would be easier. It sounds like her agitation and delusions are improved with Risperidone. Sleep issues can often be helped. Her dementia physician might consider trazodone, zolpidem, or others for sleep issues. Risperidone can cause weight gain. There are many other potential causes for weight gain. Quetiapine typically can help better with sleep than Risperidone and may be a replacement for risperidone for her agitation and delusions. Repetitive word speaking may suggest some obsessive compulsive symptoms. High doses of Lexapro or fluvoxamine (need to get to 200 or 300 mg daily) may be helpful for those symptoms. They may help depression issues. If patients are overly restless, we consider coming down on the Risperidone if it is at a high dose (more than 1 mg daily). Insomnia, feeling or acting hyper, eating a lot could suggest a hypomanic state, and the use of valproic acid or other mood stabilizers may be helpful. In regards to your predicament, the best way you can avoid burnout is to have some more respite. Consider daycare facilities, if available, in the day time so that you have more peace at home in the day. Have her "visit" and stay in a nursing home for a week so that you can get some respite periodically. You will be a much better caretaker if you can have time for yourself and have enough sleep.  

Your aunt is having delusions or false beliefs. There are many potential causes. Some medications may cause them. They are seen commonly with infections, like urinary tract infections. Metabolic derangements or thyroid conditions might also cause these behaviors. Dementia is often associated with delusions. Stress is usually not a cause just by itself. She needs to be seen by her doctor who can evaluate her for potential causes. They can also evaluate her gait disturbance and for causes of dizziness.  

You should feel good that you have your wife in a good place. Many patients require long-term care and it allows spouses to have quality time with their loved ones while getting help for their care. Some of the downsides to a change in environment is the natural reaction by the patients to want to go back to their comfort place, their previous home. Why would anyone with such impaired insight into their condition, as all frontotemporal patients have, want to leave their home and go to live somewhere else? They have no clue why they or their spouse would need any help in their care. Many times, as the patient gets use to their new home, these comments will decline. Exactly when these comments stop is different for each patient. It may help to not use terms like permanent or forever. It may be better to use terms such as temporary or trial period to get past these comments. Perhaps you can emphasize that the facility is helping to rehab or adjust medications to see how she does. Since you have done your homework in picking this place, stick with it and no regrets. 

I am not sure exactly what you’re asking. If she is supposed to take medications for her dementia or for other conditions and won’t, then crushing and placing them in her food would be advised. If she has a good appetite, giving her nutritional supplements would help her maintain her weight. These can be bought over the counter through Parentgiving, such as Ensure, Boost, Carnation Instant Breakfast and others.  

Given that your sister has the duty of caring for your father, it is important to better understand his behaviors that cause her not to want you to see him at this time. What issues does he have at night after your visits? Perhaps there are treatments to make his nights better. In general, dementia patients enjoy being around familiar people. However at times, certain family members may make them more upset or irritable. Has she allowed you to talk to him on the phone? It is understandable you would be frustrated, but the focus should be on what is best for your father.  

Caregiving is very hard work. It sounds like you are doing a fantastic job. You are keeping her mind engaged with the day care and senior center activities. However, you also need to avoid burnout, which won't help you or your mom. You also have obligations to your daughter. If your mother has the money for assisted living and you can find one close by, you can still visit and have really quality time as often as you like with your mom and yet have more time for yourself and your daughter. If your mom often does not even know who you are, it may not be a big issue for her to move into another place. You could give it a trial run for a weekend or a week to see how she acclimates to a new place. It may be best for all. At assisted living facilities, they have many activities that should keep her mind active. They have more hands to help your mom around the clock. Other options could be to hire someone to come in to care for your mother to give you more time.  

Strokes can cause cognitive impairment. His evaluation back in the US should investigate other causes of memory loss (through blood tests, cognitive tests, and neuroimaging). Frustration is normal when you are always telling him what to do. You can try to avoid telling him things and instead ask him—it will seem less like bossing him. Keep a calendar with reminders of what is planned for the day. Put up signs to remind him of certain duties so that he can do them without you reminding him. For things that you both need to do, perhaps like bathing, you can tell him that you are about to take your bath, but does he want to go first? In this way he may get less frustrated at always being told what to do.  

Simple tests can determine if she has the beginning of a dementia condition. Her doctor can evaluate her for that. Let her doctor know of your concerns regarding her memory or thinking. Also let the physician know of her sleep issues. Make sure first she is not on medications that would increase bad dreams or insomnia. There are several safe medications that are not sleeping pills that can help with insomnia or bad dreams (e.g. trazodone and rozerem among others). Also, try good sleep hygiene habits may help, including keeping bedtime and rise time the same, avoiding caffeine or alcohol at night, and not drinking many fluids after dinner. 

Your grandmother-in-law has psychosis (false beliefs). If she also has memory loss and perhaps trouble finding words, this is very likely a dementia condition. Be sure to check if she is on any new medications or increase in medications that can cause these symptoms. Urinary tract infection or other infections often cause similar symptoms. These can be treated. If no other cause is found, there are many medications that may help her psychotic symptoms, such as Seroquel at night or daily Geodon. Talk to her doctor to see if any treatment is right for her. She would likely only need a very small dose, given her age. Also if dementia is considered, treatment with cholinesterase inhibitors (donepezil, galantamine, or rivastigmine) may be in order to help her thinking and slow decline in her dementia symptoms.  

Increased edema is water weight and will definitely cause a lot of weight gain. It may also suggest increased problems with her congestive heart failure. Unless that issue can be addressed she would not be able to exercise or do any type of activities. Her quality of life depends on this. You sound like you are doing your best to convince the daughter. I would agree that it is best to let the doctor know the results of the intervention they suggested. You can let the daughter know that there may be other treatments to help her mother's edema and weight gain that the doctor can suggest. I suppose that it puts you in a difficult position, but keep in mind that anyone can call the doctor to give information without incurring any HIPPA violation.  

You say he is addicted and so I assume he is taking narcotic pain medications. Narcotics often increase cognitive issues, especially in someone who may have other causes of dementia. It is important to get his doctor involved in this situation. The physician needs to tell the patient that it is not safe for him to take his own medications due to their potential effects if he takes them incorrectly or in the wrong dose. The doctor could make it clear that, unless he allows a trusted family member to supervise the narcotics, it may be unsafe to prescribe them to him. 

There are many thickening agent products that are designed to help individuals with swallowing difficulties. These can be bought over the counter or internet. Parkinson's disease often causes dysphagia, leading to possible aspiration. Common signs of dysphagia include drooling, coughing and choking on liquids more than solids, and more difficulty talking after swallowing. The thinner the liquid (water, apple juice), the faster it can get to the back of the throat and the less likely the individual with Parkinson's disease with slow motor skills can close their wind pipe in time. If the liquid gets into the wind pipe, choking and coughing start and it may lead to aspiration of liquid or food into their lungs. That can cause a lung infection or pneumonia (aspiration pneumonia).  

Well, what you tell me is that your father is losing weight, refusing bathing, and not keeping his room clean. It sounds like he is not thinking as well and not making good judgments and this suggests a brain condition. Evaluation should include a good history, family history, social history, examination, lab tests, scan of his brain, and cognitive (pen and paper) tests of his thinking and memory. That information should help with making a diagnosis. In regards to his behaviors, close supervision, if not already present, may help. People tend to eat more and more regularly if they are eating with someone else. Nutritional supplements (Boost, Ensure, Health Shakes, Carnation Instant Breakfast, ice cream…) given regularly on a daily basis may help. Having a friend, family member, or health aide come in to bathe him may be needed. Perhaps bribing him with something he likes only if he takes a good long bath may work. At times it is easier to clean up if he is not around. Have someone take him out and then clean his room when he is away. If he is developing cognitive (memory or thinking) issues, having him appoint a Durable Power of Attorney for Health Care and Finances is critical prior to his losing the capacity to make decisions on his own. 

These situations are always difficult. Your mother needs some respite—time for herself. If children are close by, they can volunteer to take their Father for an outing to provide supervision for 4 hours or so to give her some time. Your mother can go with her husband to a Day Care Center if there is one close by so that he gets used to the staff and guests. After a few times he (and your mother) may be very comfortable to leave him under their supervision while she gets some things done for herself. If your mother needs surgery for her knee, one of the children or a respite care facility can watch and care for her husband. Your mother may also be helped by an antidepressant if indicated to help with mood and irritability issues.  

Your mother has false beliefs (delusions) and memory loss. This is probably a dementia condition, given her age. There are many causes for dementia including Alzheimer’s disease, medications, small strokes, B12 deficiency, low thyroid and many others. Her primary care physician should look for potential causes and treat accordingly. Sometimes treating the underlying cause (like replacing B12 in B12 deficient individuals) will also clear up the false beliefs. Sometimes the false beliefs require an additional medication specifically to help those symptoms, like quetiapine (Seroquel). 

Sometimes using Ativan, especially at age 93, could cause more problems than it helps. For some individuals it can increase confusion, it can cause a lot of sleepiness, and is addictive. Often a trial of an antidepressant, such as escitalopram (Lexapro) or sertraline (Zoloft), can work very well for anxiety and has many less side effects. Low sodium issues can be responsible for confusion, anxiety, appetite issues and weakness. Her doctors, if they have not already, should identify the cause of the low sodium and try to correct the underlying cause. 

There is not a lot that can be done except increased supervision and reminders so he is correctly positioned in the diaper. Sometimes placing notes in the bathroom or bedroom to put pants on correctly may be helpful for some patients. Some men have an enlarged prostate or prostate cancer, which may cause dribbling. His primary care physician can diagnose this and there may be medications that could be helpful. If he is up a lot at night, then maybe a medication to help with sleep (like trazodone, which is very safe at low doses of 50 or 100 mg nightly) might be prescribed by his primary care physician. This may reduce his nighttime awakenings for random reasons, but would not keep him asleep if he really needed to use the toilet. Reducing or eliminating liquids after dinner and avoiding alcohol (which causes increased urination) may reduce nighttime urination needs. Use of a catheter, I agree, would cause more problems than it would solve. 

There are many clinical trials for mild Alzheimer's disease and the precursor condition, Mild Cognitive Impairment. Many of these are testing experimental medications. The best place to look for trials in your area is to go to the website clinicaltrials.gov 

Many medications can cause dizziness. However, since she is not on any medications, some blood and urine tests may be in order to rule out infection, electrolyte issues, low thyroid, B12 deficiency, or liver or kidney problems. For weight loss, nutritional supplements (Ensure, Boost, Carnation Instant Breakfast, among others) can help to provide a lot of calories with a small amount of liquid. There is a liquid medication, megestrol, that is often helpful as an appetite enhancer.  

With Alzheimer's or Parkinson's disease, restless behaviors and fidgeting are not uncommon. The medications he’s on that can cause increased restlessness are Carbidopa/levodopa (typical), Effexor at times and, if giving higher doses, Seroquel. Citalopram or Depakote may be more helpful than Seroquel and Effexor for these types of behaviors. If you wish further information regarding the best behavioral treatments for these conditions, you may purchase my book, "Long-Term Management of Dementia" (Informa Press) through Amazon or click on the icon next to my picture.  

Safety is obviously your main concern here. Independence is his wish. At some point he may not be using good judgment to ride a bicycle at all. However currently it seems that he is still capable with restrictions for safety to ride one. Our typical recommendations are to avoid riding at night, in inclement weather, or in unfamiliar areas. I would tell him that state routes are off limits at this time as you have. You could bribe him to not ride on the state route. You could suggest you take him to ride in places that are safe or ride with him on weekends. If all that fails and his actions are dangerous, you could have a police officer notified while he is riding on the state route to pick him up if he is showing dangerous riding techniques. This may reduce his desire to do those unsafe practices. If all else fails and he is in danger with his riding, removing his bike would be the last resort. Another idea is to follow him (perhaps ride a bike with him) and to observe if he is using good judgment or not with his riding. If he is not, watch once a month. Once he is noted to be using poor judgment, it is time to restrict his riding.  

It sounds like she has severe anxiety, maybe panic, attacks. Make sure she is not taking sleeping medications (especially over-the-counter ones) or hypnotics. Have her physician evaluate all her medications and remove all that are not needed. If blood pressure, oxygenation, low blood sugar, sleep apnea, thyroid problems, vitamin B12 levels are all normal, she could try something for anxiety. Benzodiazepines are not typically recommended for individuals her age. Antidepressants (escitalopram or sertraline) or buspirone may be the first ones tried due to low side effects.  

It is hard to predict without more information about her other medical conditions and her current functional abilities. As you suggest, genetics can play a large part. If she is in the late middle stage as you suggest, 4-5 years more would be typical if she did not die of something else first.  

As I mentioned in the prior question, I don't believe there is any such thing as rapid onset Alzheimer's. Dementia conditions occurring right after a surgery are almost always related to medications, infections, metabolic derangements, perhaps impaired blood flow to the brain or perhaps low oxygen to the brain during the surgery. However, other coincident causes of dementia need to be ruled out. If he had the start of a condition like Alzheimer's disease prior to the surgery then he will continue to decline very gradually with his memory, language and visuospatial problems after the surgery. However, this process is gradual (months to years) and not rapid (days to weeks).  

Many people with dementia can develop false beliefs or suspiciousness. Sometimes it is caused by other medications like narcotics, carbidopa/levodopa or many others. First have his doctor review what he is taking. The caregivers might be able to reduce some of these suspicions by changing the way they approach him. They can try to empathize with his concerns and redirect to another topic if these false beliefs come up. There are some very effective medications (antipsychotics), if used in low doses, that often greatly help these types of symptoms. Whether his behavioral issues correct or not, it is likely that most nursing homes with memory care would be able to take care of all his health issues. However, the best way to find out is to visit them and explain his situation.  

Absolutely not! As long as the parent is safe and needs met, they can live where it works best for them. The only reason to consider assisted living or nursing home is usually because the person is no longer safe at home or the caregiver(s) can no longer adequately care for them. Another advantage of senior living, assisted living or a nursing home is the activities and socialization provided, which help keep the person's brain stimulated, which is thought to help brain functioning. However, your parent goes to adult day care and it sounds like she is getting a lot of good brain stimulation.  

There are no easy choices. If she is not safe at home or no longer able to care for her needs appropriately at home, she either needs the safety net of an independent living facility or in-home assistance for supervision, help with daily activities and safety needs. Many times there is a honeymoon period of adjustment when moving into a new place. For some this is short and for others it may be much longer. It is costly either way, but depends on the amount of in-home supervision required. She should continue the Aricept and make sure she increases the dose to 10 mg after one month. If there is some evidence of depression, irritability or anxiety, an antidepressant (such as sertraline or escitalopram) at a low dose may be helpful for the adjustment period. Ask her doctor if any of those are appropriate for her.  

Your mother has symptoms of delusions, which are false beliefs where no amount of logic or persuasion will change her mind. Typically, trying to interject reality will cause anger and disbelief on her part. Empathizing with her concerns (it would be terrible that strangers are having sex with her) will allow her not to get too angry at others. Some medications can cause these symptoms. Check for any new medication she is taking. Infections like urinary tract infections can cause such symptoms. Significant liver of kidney disease, electrolyte imbalance or endocrine conditions as well as other conditions can also contribute to these types of symptoms. If the delusions are longstanding, it may be due to a dementia condition like Alzheimer's disease. If she had dementia she would also have significant short-term memory loss. It would be unlikely schizophrenia, as that condition starts much younger as a general rule. There are many choices of medications that help delusions called antipsychotics. Her doctor should be able to decide if she is a candidate for any of those treatment choices.  

Normally the individual should decide what time they wish to go to bed. Keeping good sleep hygiene (maintaing routines for sleep and wake times and turning off distracting lights or noise at bedtime) is very important to a dementia person's functioning and for good sleep habits. If the individual is attempting to go to bed very early and then is waking up in the middle of the night causing disruption to others, we would suggest increasing pleasurable activities to keep them up to a more suitable bed time. If the individual is tending to go to bed too late, avoiding naps in the day, eliminating TV or other distractors at normal bed times or if needed, giving medications to get their sleep/wake cycle under better control may be helpful.  

Aricept (donepezil) in a small proportion of patients can cause loose stools or bowels and weight loss. If no other cause is found, donepezil may be the cause. Adding fiber to the diet daily may be helpful. Rivastigmine (Exelon) patch in some individuals will produce less gastrointestinal issues since it is a patch and not a pill and circumvents the stomach. It can be given in place of donepezil. Adding nutritional supplements to his diet may also help with weight since he has a good appetite.  

If his appetite is low, consider supplementing his food intake with nutritional supplements such as Ensure, Boost, Health Shakes and others. They pack a lot of calories in a small amount of liquid. There are also medications that may help with appetite (mirtazapine, megestrol) that you can talk to his doctor about. If he is having trouble with chewing or swallowing, the only solution is to make his food softer to make it easier to swallow. If he is choking on liquids or food he should see his doctor. There are also products to thicken the consistency of liquids to make them not cause choking as much.  

 Alzheimer's patients often get to a point that they do not know how to look for or seek out food. They may lose language abilities that they can not express their desires that they are hungry. Depression should always be looked for. Crying spells, “wish I were dead” comments and apathy are all signs to watch out for.

Many demented patients have a tough transition when moved to another environment, especially when familiar people or things are not present anymore. Often over time (and that varies with the individual) they acclimate to their new home as they get accustomed to the staff, other residents and their environment. Depending on the stage of their disease and the degree of comprehension of their environment, that can take a long time in some cases. Some patients do better if the family visits often and others seem to do better if out of sight, out of mind. It depends on how he reacts to family to determine if that is more anxiety-producing than not. Anxiety and depression can be treated very well during the adjustment period and I would talk to his doctor for consideration of starting a medication to help.  

Evaluation is needed to find the cause of her false beliefs including memory screening and assessments. Please see the answer below for more details. 

What you are describing, false beliefs can be caused by many conditions. Certainly people with dementia (Alzheimer's disease, Lewy body dementia, Parkinsonian dementia and others) can have false beliefs due to their dementia. However, certain medications in some people may also cause false beliefs (steroids, anticholinergics, antihistamines, pain medications, amiodarone, mexiletine, antiarrhythmics, many antibiotics, sleeping pills, anticonvulsants, some antihypertensives, anti-Parkinson agents, and others) in some individuals. Toxins like alcohol can cause false beliefs. Lack of oxygen to the brain (hypoxia) from sleep apnea, COPD, poor heart function can cause false beliefs in some individuals. Significant liver or kidney disease can cause this. Low B12 or thyroid abnormalities can cause this in some people. In short, just because here are false beliefs does not mean the person has dementia. A careful and complete evaluation should be done to find the specific cause. There are medications that can reduce false beliefs (antipsychotics) that may be considered by their physician.  

The usual goals of care would include safety and quality of life. Increasing pleasurable activities and using day care centers to increase brain stimulation may help quality of life. Look at all his medications to make sure they are not sedating him. Make sure that all caregivers get enough respite so that they can increase the amount of quality time with him. Consider a companion to get him out of the house.  

There is great variation of care provided in Assisted Living facilities. For some "memory care" is just having a locked unit where the dementia residents stay so that the Assisted Living facility can advertise they have a special place for dementia residents. The best places not only have secured units, but also have extensive training in the care of dementia residents. They have dementia specific activities based on the individual resident's level of functioning. They have more, rather than less, activities that are resident specific. They have environmental cues and stable nursing staff to help provide routine and stable environments for those with memory loss. They have training regarding behavioral modification techniques and ways to improve communication to those with dementia. They have training with ways to approach and care for those with fear, suspicions, anxiety, intrusiveness, and agitation other than always using chemical or physical restraints. They have expertise with their physician staff who know when and with what medication (behavioral stabilization and cognitive enhancers) using the appropriate dosing will lead to improved quality of life for a specific resident. They communicate routinely and often between each other and with their physicians to notice issues early and to take appropriate actions early. In looking for an assisted living facility you can ask about the topics I mentioned above. You can also ask how often they have to send a resident out to the hospital for behavioral or dementia issues or how often they give someone a 30 day notice to leave due to the resident's behavior or dementia issues. The best facilities rarely have to send the residents out or away as they have great staff and the training to appropriately care for the resident in place. Good luck on your search. 

If the shunt that was placed malfunctions or is clogged, it can cause acute hydrocephalus leading to severe headaches and lethargy leading to unresponsiveness. If there is an infection of the shunt in the brain, that can lead to sudden and severe cognitive impairments. A bleed in the brain related or not to the shunt (subdural hematoma, cerebral hemorrhage) can cause rapid deterioration. Degenerative dementias never progress in a matter of days. A CT head of his head or a shuntogram can help with diagnosis of the problem.  

I am sorry that you and your family have had to go through all of this turmoil. I am not sure of your question. Do both parents have dementia? Is it your mother or father that has all control? If your father continues to drive, is not using good judgment in his driving and is not safe, then disabling the car or removing it may be potential options. If your mother is overly controlling, you need to discuss with her that her husband's dementia syndrome will decline more slowly in the future by getting and staying on Alzheimer's medication if that is what his doctor is recommending. The longer the husband stays functional and able to take care of day-to-day activities, the less work it is for the wife. If it is the husband that is controlling, the family must try to do what they can to keep him safe. His doctor needs to bargain with him to just try the medication temporarily to see if he likes it or if it seems to have benefit. For a fair trial, make sure he gets up to the best dose. After a couple of months, the medication may be more routine and he will not complain about taking the medication or the doctor can suggest to keep on it a little while longer to see how it does.  

 Medications can often cause hallucinations. Of the ones you listed, meloxicam might cause issues in some individuals, but it is not common. The other medications do not typically cause these issues. If any of these medications were started just before these behavioral symptoms started, then talk to her doctor about coming off that medication if possible. It is possible that she is having false beliefs or delusions and not specifically seeing or hearing things (hallucinations) that others do not see or hear. Seroquel is a medication specifically for these false beliefs. Perhaps she was started on it for that reason. The usual does range for Seroquel is 50 mg to 150 mg total dose daily in dementia individuals. Since there are many causes of these behaviors, including infections (urinary tract infection), metabolic disturbances, environmental considerations, among others, it is best to get her back in to her physician so they can make sure she does not have an infection and to check for other causes to treat.

If you have a Durable Power of Attorney (DPOA) for healthcare and your mother no longer had the capacity to make these decisions on her own and your father and siblings are all agreeable to place her, then there is no need for guardianship and you can make the arrangements to place her in a long-term care facility. If there is disagreement between family members, this becomes harder to do and then a guardianship may be the best option. To get a guardianship, you will need her physician to fill out paperwork obtained from the courts to provide information on her capacity. The courts then decide if a guardianship is appropriate and who the guardian will be. They may choose a non-family member. Another option is to contact Adult Protective Services to come into the home and evaluate the situation, particularly if you feel that her husband is not taking care of her properly. They can help as well in getting the process started for a guardianship if they feel that is needed.  

There are many potential reasons for her behaviors and so it will be hard to be very specific. In general if your daughter can bribe her with something she likes to eat or do, this may help. In other words increasing pleasurable activities usually helps. Perhaps you calling Barb just after she arrives home may ease the irritability. If none of that helps, you could talk to Barb's doctor about medications, like antidepressants that may help calm her a bit more.  

 Yes. In some individuals who have frequent urinary tract infections, physicians at times prescribe daily low toxicity antibiotics to help prevent them from occurring.

Many things may cause false beliefs or hallucinations in elderly people. An infection such as a urinary tract infection or pneumonia could cause this. New medications or overdose on medications is another common cause. Metabolic conditions or liver problems may cause these symptoms. If they are recurrent and especially if they are associated with fevers, confusion or other new symptoms, your grandmother should be seen by her physician.  

Behavioral issues are common in those with dementia. They are due to loss of brain cells and due to neurotransmitter changes in the brain related to the brain damage. Environmental or behavioral modification techniques can be helpful to reduce unwanted behaviors. However, they are often not enough and medication supplementation is often required to help even out the neurotransmitter impairments. Agitation, irritability, false beliefs and mood issues can often be relieved dramatically with appropriate pharmacotherapy. If your mother has fewer of these behaviors, it is much easier to care for her. Your father may also benefit from more respite. You could have your mother go to day care, have a paid caregiver come in or take her out or have family watch her while your dad gets some time to himself. Regular respite is invaluable and reduces burnout for caregivers. To evaluate how negatively she would respond to a nursing facility or assisted living facility, she could be taken there for a weekend or a trial period and see how she reacts. Many facilities have all levels of care in the same campus (independent living, assisted living and nursing home). A husband could be very close even if a wife has to move to the nursing facility when more care is required. Your local Alzheimer's Association chapter or Area Agency on Aging could give you a list of facilities that have those choices. My edited book, "Long-Term Management of Dementia" (Informa Publishers) has great information about all these management issues and much more (see the link next to my expert column at Parentgiving). 

Parkinson's disease usually starts with tremors/shaking on one side much more than the other. The shaking is worse when the hand is at rest and much less when the hand is moving such as when drinking from a cup. Other features are stiffness, lack of facial expression, slowness of movements and trouble with balance. When the shaking or tremors affect both sides of the body or head or jaw and are worse when trying to write or move, Parkinson's is less likely. Essential tremor, medication or toxin-induced tremors or familial tremors are more often the causes. Individuals with restless leg syndrome have a desire to move the legs or sometimes the arms and a feeling of not being comfortable. It often keeps them up at night. Medications for anxiety can also at times increase tremors as can other medications like those for asthma or breathing issues. My suggestion is to seek out a neurologist for a complete evaluation of potential causes and treatments.  

 Any activity that helps stimulate the brain is helpful for dementia patients…in moderation. Too much stimulation of anything can cause anxiety and confusion. A variety of stimulating activities at different times is better than only one activity. Music therapy can be very helpful to calm a person and stimulate certain parts of their brain. As with any activity, if the patient responds to it, it is worthwhile to continue. If their response is more anxiety or distress, then it is worthwhile to discontinue it.

About 70 percent of individuals with dementia, particularly with Alzheimer's disease, develop false beliefs. Only 3 percent develop hypersexuality with physical sexual aggressiveness. However, more commonly we see frequent verbal sexual comments. Typically, one can first try to use logic to dissuade the patient of their false belief or try to ignore the behaviors if they are not harmful. However, many times these techniques do not work due to the nature of the condition. When the behavior issues get to a point where they are causing significant problems for the patient or others, it is time to consider medications. Due to the potential seriousness of the accusations, use of an atypical antipsychotic (like quetiapine or ziprasidone or risperidone) to help reduce the false beliefs may be something his doctor may consider. There are also medications that may help with hypersexual behaviors, particularly antidepressants like selective serotonin reuptake inhibitors. Chapter 4 in my edited book, “Long-Term Management of Dementia” (Informa) goes into detail about dealing with problem behaviors if interested (see the link next to my expert column). It is also important that these concerns get documented by his primary care physician or dementia specialist. Evaluation and management of these problems by his physician, including a clear diagnosis of his dementia will help in case there are any legal issues that arise. If the behaviors are not treated, it may not matter where he lives as he may have the same accusations everywhere he goes. This is more typically the case than not. 

You can lose a lot of weight quickly if the weight is from water or fluid loss. Some patients are on diuretics that will cause them to urinate out excess fluids that may be building up in their legs or elsewhere. I would have her seen by her primary care doctor to look for reasons. 

I suppose it is possible they weighed her incorrectly. However, in general, patients with this low a weight who have dementia have a very hard time gaining weight. Also, a person can become dehydrated and lose a lot of weight if they are not drinking or eating much for two days. It is possible after her bladder infection is corrected, she will gain weight again. Continue supplements with or between meals and eat with her to help with weight gain. There are some medications that can also improve appetite (mirtazapine and megestrol), but they also may have significant side effects to watch for. 

Exelon at 9.5 mg/24hour patch is an effective dose for individuals with Alzheimer's disease. This medication is often combined with memantine titrated up to 10 mg twice a day. I have no experience with the use of cerebrolysin as it is not often used in the United States. More studies are needed for that agent in regards to how long it can remain effective for patients. Vitamin E 200 units daily can be helpful as an antioxidant in Alzheimer's disease patients. There have been encouraging signs from the monoclonal antibody "vaccine" against amyloid in human studies. More research is required to see how well it works. The same is true for the other passive and active approaches. If he is eligible and willing to participate in a clinical trial and there is a center close by doing these trials, I would be very supportive of getting involved. Altruistic patients with Alzheimer's disease wiling to participate in research will help to speed up the discovery of new therapies for them and others. 

There is no question that he would be best served by a physician who specializes in dementia. It would not matter if they are a neurologist or psychiatrist as long as they specialize in dementia. 

There are many potential reasons for dementia and most are treatable. His physician can assess for potential treatable causes and start appropriate treatment to help the condition. Some causes of dementia are treated by surgery like those with hydrocephalus. There are also some cases of Parkinson's disease where the symptoms can best be treated with deep brain stimulation or surgery. Potential candidates must be evaluated at specialized centers that offer these treatments. His neurologist would be able to let you know if he would be a potential candidate. 

Sorry to hear about the situation. It sounds like she may be suffering from a progressive degenerative condition. However, there may be treatable issues if she would allow an evaluation. This may not be possible until she gets so ill or gets an infection that she has to go to the hospital. She also sounds like she is a bit suspicious and maybe paranoid. Many times medications will help her behaviors enough that she would be more amenable to increased supervision, a shower, food, and an evaluation. Since no physician will prescribe without seeing her, it may be possible to get a visiting physician to come to her house when you are coming out to see her. They may assess the situation as dangerous to her and Adult Protective Services may have to come out. They may be able to get enough of a flavor of her behaviors that they may be willing to prescribe a medication. Some medications like risperidal come in liquid formulation and can be placed in something she drinks if she refuses to take any pills. You may have to visit daily to make sure she drinks her drink with the medication in it. This may help her suspiciousness and increase her willingness to allow more supervision and evaluations. Best of luck. 

Many times if there is a sudden change after surgery, it suggests that he is suffering from an acute confusional state. There may be many causes. The most common causes include medication effects, infection or strokes. Metabolic issues like impaired liver or kidney function can play a role. Not getting enough oxygen (short of breath) can be a cause. A scan of his head would rule out a stroke. Infection from the surgery or other causes (urinary tract infection) can lead to confusion. Often after surgery people are placed on pain medications and many of these can cause confusion. The faster he can get off these medications the better for his confusion. Anesthesia should wear off and would not cause long lasting impairment. Those individuals with underlying dementia would have less cognitive reserve and so will be much more sensitive to having medications, infections or other conditions cause a confusional state. They will recover most of the time completely, but it may just take a few weeks. Alzheimer's disease is a gradual progressive condition and there is no such thing as rapid onset Alzheimer's disease. If there is a sudden change in cognition there is always something else (maybe in combination with a mild dementia) as the main cause of the issues. 

There are many ways to help with sleep. First, try to make sure she does not nap in the day. Avoid alcohol and caffeine. Keep on a strict sleep schedule, go to bed and wake up the same times each day. As far as sleep aides, the least toxic for Alzheimer's disease is trazodone, maybe 50 to 150 mg nightly. Avoid all over the counter sleep aids as they can make her confusion worse. Other that can be tried include mirtazapine, zolpidem, gabapentin, and others. My book, Long-Term Management of Dementia (see information to the right of my column on Parentgiving) has other choices listed. 

Supplements are the first best choice. Ensure, health shakes, Carnation instant breakfast, Boost and others are all pretty good. Start with one can a day. However also make sure that someone eats with him as this will usually increase food intake. There are medications that can stimulate appetite like mirtazapine or megestrol. These can work very well in situations where there is severe appetite loss. However both can have side effects that are best avoided if supplements will work. 

Hospice care usually means end of life care to keep someone comfortable just prior to death. However, the amount of treatments given while in hospice care is usually left up to the doctor and family. Some families will treat infections, like pneumonia with antibiotics. Some families will not treat and just provide comfort care. Morphine is often given to help with pain issues and anxiety symptoms to make the patient comfortable. Ativan can be used for sedation or anxiety. Just prior to death, no food and limited water makes the patient more comfortable. Too much fluid may build up in their lungs giving a sense of drowning. Fairly soon the patient cannot drink anymore and death ensues quickly and comfortably. Often the patient may have made a Living Will that instructed family members that he would not wish to live if certain irreversible conditions became so unbearable that it made his life not worth living anymore. Exactly what medical issues or combination of medical issues occur that lead to that conclusion is very variable for different patients and different families. 

Anyone age 87 with progressive memory or thinking problems is very likely to have a degenerative condition like Alzheimer's disease. Her doctor should have run some lab tests and a scan of her brain to look for reasons for her memory loss. Dementia is a non-specific symptom, meaning someone is having trouble thinking and doing day to day activities. One cause of dementia is Alzheimer's disease, which is due to an abnormal accumulation of toxic proteins that accumulate in the brain and kill some of the brain cells, particularly in the memory areas. Dementia can also be caused by head trauma, having many strokes, low thyroid, vitamin deficiencies, kidney or liver problems or drugs, to mention a few other conditions. Many causes of dementia can be treated including Alzheimer's disease. I would ask her physicians what type of dementia they think she has. Then get more information about that condition. Visit the Alzheimer's Association for information and think about going to a support group meeting where you live. Inform the assisted living facility of the types of activities your mother would enjoy so that they can direct her to those types of activities. 

It is alright to reorient your mother to reality if it does not cause her significant grief and anxiety. If reminding her that her husband has died many years ago causes her much distress or disbelief, then it may be better to change the subject. You might agree that it would be nice to visit with him (her husband) and that it may be something to think about later. 

In regards to your mother-in-law, yes, significant kidney dysfunction can cause dementia. Toxins in the blood that the kidneys normally would remove may not be removed as well and so more get into the brain and effect its functioning. However, many conditions that affect the kidney (e.g. diabetes) can also affect the brain as well. If the dementia is only from the kidney dysfunction, it can be partially reversed by correcting the kidney problem or giving dialysis. If the brain dysfunction is due to several conditions then reversibility is less likely.

In regards to your aunt, given her long history of progressive decline, a degenerative brain condition is most likely. Those conditions, like Alzheimer's disease or dementia with Lewy bodies have a fairly predictable course. Patients lose more and more abilities to do day to day activities. The rate of decline is usually fairly stable and the speed that she has declined can help predict how fast she will continue to decline. Obviously UTIs, intercurrent illness, diet issues and other conditions can cause fluctuations in her bowels, incontinence, thinking and moods. Her physician can help with these intercurrent illness or conditions. Another excellent source of support and information about prognosis may be obtained at Alzheimer's disease support groups where families going through similar issues can share their experiences.
 

In general, trazodone is a very safe medication and often helpful for sleep issues. It is best taken every night to promote sleep. I use it often in dementia patients. It can be titrated to effect, usually helping with dosages from 50 to 100 mg nightly. In specifics for your father, it would be important to talk to his physician so that they can review his medical issues and other medications to make sure that he would not have problems taking trazodone. None of the conditions you mention that your father has would necessarily be contradictory to taking trazodone. It would most likely work fine, but his physician would have to review his case prior to prescribing it. 

There are many potential causes of cognitive problems including medications, thyroid issues and vitamin B12 deficiencies that are completely reversible. Other causes including degenerative conditions like Parkinson's disease dementia or Alzheimer's disease are very treatable and those medications help to slow down the cognitive decline. Both family members need to be evaluated by their primary care doctor for causes of their impairments. Also family can ride with the mother-in-law to ensure she is still using good judgment with her driving. If there are questions regarding her driving skills, driver evaluation centers can be contacted for professional evaluations. 

You mention that she removes all her clothes after bedtime. Does that mean she originally goes to bed with them on? If that is the case, perhaps using a medication that promotes sleep like trazodone may help her sleep through the night and decrease the times she wakes to remove her clothes. Is any one living with her? If she has a bed alarm, or a baby monitor, the other person could be notified when she gets up and assist her to the toilet to prevent falls. Consider also the use of a commode at the bedside, which should reduce the time to reach the toilet and perhaps she will make it on time to the commode. Also be sure to enforce no fluids after dinner. Avoid caffeine or alcohol as these promote urination. Hopefully some combination of these ideas may be helpful to your situation. 

I am sure it is very disturbing to see your father like this. At the end stage we are focused most on quality of life for him. Certainly if part of his agitation is due to pain, that should be addressed. Also a review of any medications he is on that can increase confusion or agitation would be suggested. With the broken ribs, is he breathing well? Air hunger will cause agitation and confusion. Getting good sleep at night is always important. Trazodone may be of use if needed. The key, however, is to control his agitation and, do to that, one needs to figure out the cause (anxiety, air hunger, pain, fear, restless...). If his agitation is improved, then he has a better quality of life. Good luck.
 

In Seattle, the first place I would suggest your mother be evaluated is at the Alzheimer's Disease Research Center at the University of Washington. They have expert neurologists who specialize in Alzheimer's and cognitive disorders. Dr. Murray Raskind is the Director of their center. Residents of other cities can get on the American Academy of Neurology website to "find a
neurologist in your area." That website is: http://patients.aan.com/go/home
 

The term dementia is a symptom and not a condition. Dementia just means that someone has trouble with thinking and functioning. It does not tell anyone what the cause of those symptoms are. Some causes of dementia are multiple strokes, head trauma, Alzheimer's disease, Parkinson's disease dementia, alcohol toxicity, medication toxicity, etc. Your mother's physician should have completed an evaluation to determine the cause of her dementia symptoms (her thinking and functioning problems). You can have a diagnosis of Parkinson's disease without dementia (just called Parkinson's disease) and you can have Parkinson's disease with dementia (called Parkinson's Disease Dementia). In some cases, those with dementia and Parkinsonian symptoms (stiffness, balance issues, tremors, slow movements) have a condition called dementia with Lewy bodies. It is possible to have Alzheimer's disease and Parkinson's disease, but that would be very rare and very unlucky.

In regards to the anorexia, there could be many causes. Some people with Alzheimer's disease, Parkinson's disease, Parkinson's disease dementia, dementia with Lewy bodies and other dementia producing conditions can be a cause of poor appetite and weight loss. Providing increased supervision during eating times, providing foods they like to eat, and providing nutritional supplements (Ensure, Health Shakes, Boost, Carnation Instant Breakfast, others) often help. Her doctor should look for other causes of appetite loss like the use of certain medications (cholinesterase inhibitors for example), gastrointestional conditions, renal or liver conditions, thyroid conditions, etc.
 

Unfortunately, broken femurs lead to significant disability that the patient may never recover from. This is especially true for those individuals with dementia who are unable to learn new procedures well. Watch for symptoms of depression as that condition can be treated with antidepressants. Sometimes appetite loss is a sign of depression. I would not go higher than 20 mg of Lexapro. If her compulsive habits are contributing to her appetite loss, sometimes fluvoxamine at higher doses may be helpful (most patients may need 200-300 mg daily in divided doses slowly titrated to effect). In regards to the anorexia, there could be many causes. In some people dementia conditions by themselves can be a cause of poor appetite and weight loss. Providing increased supervision during eating times, providing foods they like to eat, and providing nutritional supplements (Ensure, Health Shakes, Boost, Carnation Instant Breakfast, others) often help. I have found megestrol acetate (400-800 mg/day in two divided doses) may help with appetite. Her doctor should look for other causes of appetite loss like use of certain medications (cholinesterase inhibitors for example), gastrointestional conditions, renal or liver conditions, thyroid conditions, etc... The term dementia is a symptom and not a condition. Dementia just means that someone has trouble with thinking and functioning. It does not tell anyone what the cause of those symptoms are. Some causes of dementia are multiple strokes, head trauma, Alzheimer's disease, Parkinson's disease dementia, alcohol toxicity, medication toxicity, etc. Finally remember you can only do so much to help her and it seems like you are trying everything you can do. Sometimes the disease conditions take over and we are left with our loving support
 

If your mother has not already been evaluated for her memory loss, she needs to be seen right away. There are many causes of memory impairment that are reversible. Some examples include certain prescription medications, some over-the-counter drugs, sleep apnea, low thyroid, vitamin deficiencies, and many others. Even if she is found to have a degenerative dementia like Alzheimer’s disease, the earlier she starts on treatments, the slower the decline of her memory and functional abilities. This allows her to be a functional caregiver for her husband for a longer period of time. It may also be a good idea to get an in-home assessment to identify potential safety issues in the house and to suggest possible home modifications to make caring easier. In addition, providing more supervision and increased respite opportunities will help to prevent early burnout.
 

There may be limited options. It would be most important to know how severe the neck fracture was and how unstable his cervical spine is because of the fracture. If there is substantial risk to cervical spine stability and he does not wear his collar, then it may be worth the risk to have surgery to stabilize the neck. Other options may include placing a more secure neck
brace that is harder to remove. If his fracture is not that unstable, it may be better to go without any collar than have him constantly tug at his neck, trying to take a collar off. Another option: Placing mittens on his hands may reduce his ability to loosen or remove his collar.
 

A toileting schedule can be very useful to prevent incontinence and urgency issues. However, I typically do not have them toilet every 2 hours while they are sleeping. This would be especially true if it appears that waking him is disrupting his sleep cycles and making him irritated. Unfortunately, I am not aware of any studies that have looked at this. 

There are several things to consider that may be helpful. During the day, increasing daytime activities and reducing the chance for naps may help him fall asleep more easily at night. Also avoiding liquids before bed reduces the waking at night for toileting. Medications, pain issues and mood states may all lead to sleep disturbances that should be considered. To help with sleep issues, trazodone, an antidepressant, helpful to promote sleep, can be given at night. This may help to reduce sleeplessness without any hangover effect the next day. Zolpidem may be another choice to try to help with sleep issues if trazodone is not useful.

If he has significant false beliefs or suspiciousness or paranoia, then an anti-psychotic medication may be the correct choice to give. Perhaps lowering the dose or giving it in the late afternoon may help with the evening behaviors and not cause next day side effects.
 

One of the best techniques is to get your mother on a toileting schedule. That is, have her sit down on the toilet every 2 to 3 hours whether she has to go or not. This will reduce the urgency and her not getting to the toilet on time in many cases. At times, patients may not like to be told what to do. They may also not like to be told to go to the toilet every 2-3 hours when they do not feel the need. Often suggesting that you are also going to use the toilet but do they want to go first, may ease their notion that they are being picked upon or bossed around. Giving them other excuses to go use the toilet may be helpful such as suggesting that they should go to the bathroom before they go out, etc. Also try to avoid prescription medications to control urinary leakage or incontinence as they often reduce the effectiveness of medications that are helpful for memory such as Aricept, Exelon or galantamine.
 

Parkinson's disease treatment will vary depending on the stage of the disease and the patient's other medical conditions. Unfortunately I cannot be more specific. Most medications for Parkinson's disease and for diabetes do not contradict each other. 

It would be hard to be specific with any recommendations for medications, not knowing her condition and medical issues. However, consider anxiety or mood as a contributor to pain when turning. Use of an antidepressant (SSRI) or divalproex sodium may be considered. Also, if it has not already been addressed, the type of bed or chair that she lies in may make a big difference in her pain issues when she is turned. Specialty beds and chairs should be discussed with her therapists.
 

If she has not had a medical evaluation for her memory issues, this would be suggested. Many conditions causing memory loss are reversible or treatable. Checking for thyroid issues, vitamin deficiencies and metabolic problems should be performed. Looking at her medication list to eliminate those medications, where possible, that can cause cognitive issues and confusion could also help. If a degenerative disorder is thought likely, starting anti-dementia medications will be very helpful. Behavioral modification techniques can be used to help reduce her anxiousness about wanting to go home in the evenings. It is always nice to be "home" especially as evening is coming. For many people trying to redirect her to the reality that she really is home does not often work. So, empathize with her concerns. Tell her that it is getting late and that she should stay here for the night and you will have her home first thing in the morning. Tell her not to worry and that you will be with her until she gets home. If she has other symptoms of false beliefs, paranoia or suspiciousness, talk to her doctor about possible medication use (antipsychotics) that may be considered. If she has other symptoms of anxiety, angst, or fretfulness, talk to her doctor about possible medication use (anti-depressants) that may be considered.
 

It sounds like you are saying that your husband is having hallucinations and false beliefs. These types of symptoms in dementia patients are common and are usually very treatable. If the symptoms are mild or infrequent, changing the subject or empathizing with the patient may be all that is needed. If the hallucinations and false beliefs are persistent and causing a lot of distress, then use of low dose antipsychotic medications can be very useful. His physician can prescribe such medications if needed. Locked units are to protect patients so that they will not wander away. I am not sure if he has these issues. If he is safe where he is currently living or after behavioral treatments, then there may be no reason that he would have to go to a locked unit at this time. 

Hopefully you have some respite as it appears your mother requires much supervision and care. In regards to the dementia component, you are probably doing what you can with the Exelon patch. The dementia will continue to progress unfortunately. There may be some help for her behavioral issues. You mention paranoia and false beliefs. Some Parkinson medications may cause these symptoms (Sinemet, Requip, Parlodel, Amantadine, others). Perhaps her physician can taper down on some of these medications if she is on any and this may help. At times adding a vey low dose of an antipsychotic like quetiapine may be in order to help with those symptoms. The motor symptoms may be difficult to treat except for close supervision and aid when she ambulates. If she is fainting due to low blood pressure with standing there may be some medications that can help that. Sometimes frequent urination may be an obsessive-compulsive behavior and not related to bladder issues or UTIs. At times high doses of antidepressant medications (SSRIs) like fluvoxamine may be useful to reduce the repetitive behaviors. If the behaviors are worse at night and she is up constantly, trazodone may be useful to help with nighttime sleep promotion. Talk to her physician about all these issues. 

There are many causes of weight loss and this should be addressed by her family physician. However if she has a good appetite, trying nutritional supplements such as Ensure, Boost or Health Shakes or similar products 1 to 2 cans daily may help to keep her weight up. Carnation Instant Breakfast, ice cream and other more calorie-laden foods may also work. In many of those with dementia at the end stages, weight loss is an issue. However, this is not typical in earlier stages. In more severe cases, there are appetite enhancers (medications like mirtazapine or megesterol) that may help reduce weight loss. These can be discussed with her doctor to see if they are appropriate for her. If your mother does have dementia, make sure she has an evaluation to find out the cause so that she gets started on treatments that may be available. Treatments usually work better if started earlier and not put off for months or years. 

Every community is much different in their availability of support groups. The first place I would contact would be the local Alzheimer's Association. They may know of such a support group or help you start one. Other organizations that may help include the Alzheimer's Foundation of America, Children of Aging Parents (http://www.caps4caregivers.org), National Family Caregivers Association (http://www.thefamilycaregiver.org) and ParentGiving. Some of these organizations have chat rooms and message boards that can be utilized as well. 

Most of the time those with Parkinson's disease will have more problems (like tremors or slow movements) on one side of their body more than the other. Usually they may get symptoms on both sides, but almost always one side is worse than the other. Medication adjustments may help these new symptoms. Stem cell research is ongoing but not available outside of research. Deep brain stimulation (DBS) has been approved for some Parkinson's cases and can be done in some centers. This is usually reserved for those patients that are refractory to medications. 

Taking medications in pudding, applesauce or yogurt does help in patients with swallowing problems. Most medications can also be safely crushed and place in food or drink if they are not coated or not special extended release formulations. It would help to know when she is refusing to let you feed her the pudding with the medication—whether it is the sight of the medication or just the food or that at the moment she is not interested in eating and wants to be left alone. If it is the sight of the medication, crushing the medication to hide it in the food may be helpful. If she is just not interested in eating at that time, try changing the timing of the medication administration to when she is hungry. Also try to front-load her medications all in the morning if possible—you need to talk to her physician about any medication timing changes—when she is more in the mood to take her medications. Also check with her doctor to see if any more of her medications can be switched to liquid formulation as sometimes they will accept something to drink more than something to eat. It sounds like the use of Seroquel at night is helpful for her behaviors. You may talk to her doctor to see if an additional dose one hour before she normally develops her "attitude" in the afternoon may be advised. Ativan typically is to be avoided in most dementia patients because if given too often it will cause confusion and sleepiness and is addictive with withdrawal symptoms. Antipsychotics, like Seroquel, may be a better choice to help with certain unwanted behaviors. It is far better to avoid physical restraining if at all possible for many reasons (i.e. safety, psychological). I have written extensively on behavior management in dementia in my book, Long-Term Management of Dementia (Informa Healthcare Publishers). Best of luck to you and your mother. 

If they like to do the activities or like the socialization, then as often as they can afford it or are able to. Encourage any of the activities that they enjoy (it doesn't matter what the activity is); otherwise they will not continue to do them. Even if they do not participate, they will get good brain stimulation just watching others. 

It appears your father does not recall your conversations due to memory issues. He also seems to have poor insight. I assume he needs an assisted living facility as he is having trouble with performing day-to-day activities. It sounds like he is concerned and anxious about when he will return "home." Most likely he will continue with these concerns. Sometimes it helps to not tell patients with dementia or Alzheimer's disease that something is permanent (as indeed it usually is not). I would say that "temporarily he is staying in this new place." Perhaps you can mention that temporarily he is there since his wife has been ill (health problems and depression). Sometimes making a permanent note and placing it in a place where he can see it will remind him that he is at the new place for now as his wife has had health problems. Generally over time, as people get more accustomed to the new place, they will ask less and less. They will usually have less anxiety about being away from their spouse. If the anxiety does not get better, sometimes an antidepressant (such as sertraline or citalopram) will help. 

There is no relationship between most forms of dementia and kidney stones or urinary tract infections. However, if the kidney function is very poor, it does not filter out toxins in the blood and they can build up, leading to uremia and a dementia condition. These ailments are not an indication of widening effects of dementia. That is, dementia does not cause these types of conditions. Prognosis would be impossible for me to speculate with so little information regarding your relative's case. 

Typically people that inherit Alzheimer's disease from their parents will get the disease at about the same decade in life as their parents did. However, since you have been worrying about this, it might be useful to talk to your primary care physician. They can test your thinking and memory to see if there are problems and also get a good baseline to compare to future years ahead. One simple screening test they can consider using is called SAGE (Self-Administered Georcognitive Examination). This self-administered test is best taken at your doctor's office so that they can score the test and interpret the results. Your primary care physician can download SAGE from the web (sagetest.osu.edu) and give it for you to take. 

 Many patients with dementia develop behavioral problems, which are very treatable. These behaviors are a direct result of the damage in the brain from the dementia condition. In addition, infections like urinary tract infections, anticholinergic or other mind altering medications, and other medical conditions will exacerbate these behaviors or cause new behaviors. Treating any underlying infections, reducing specific medications or resolving medical issues may help reduce problematic behaviors. These behaviors are also treated by judicious use of psychotropic medications meant to adjust neurotransmitters (chemicals) in the brain that become imbalanced due to the dementia condition. In your grandmother's case, she is displaying a lot of suspiciousness, false beliefs and agitation. Trying to use logic or trying to re-orient to reality will usually not work very well. Medications are often necessary to help with these types of behaviors. Atypical antipsychotics may be advised for similar behaviors. Please talk to her dementia physician or primary care physician about the possible use of psychotropic medications to help with her significant behavioral problems. I have written extensively on behavior management in dementia in my book, Long-Term Management of Dementia (Informa Healthcare Publishers). Best of luck to you, your mother and your grandmother.

To find a doctor knowledgable in your condition, there are several places you can contact. First ask your primary care physician who they might recommend. Call the Alzheimer's Association in your area; they often know which doctors in your region are specialists in FTD and Alzheimer's. Call your regional medical center; they can refer you to their Neurology (or Psychiatry) Department who will know who in their department is
knowledgeable for your condition. 

Alzheimer's disease often does not cause gait or balance problems until late in the disease. Balance or walking problems may occur earlier if apraxia (difficulty in sequencing movements to result in a smooth gait) exists. I would talk to her physician to ask if there may be other causes for her walking issues. 

There are many medications that might be useful for depression and anxiety associated with Alzheimer's disease. However, do not confuse apathy (no interest in doing things) with depression (sad, crying, feeling low). Not wanting to go out of the house or not wanted to perform tasks may represent more apathy symptoms than depression. Apathy is not helped much by antidepressants. It can be helped by Aricept. If she does have apathy, you may wish to maximize her Aricept. If she is not taking 23 mg every morning, that would be a consideration by her physician. If she has significant depression or anxiety, one could increase her Lexapro (maximum dose 20 mg daily) or switch to another antidepressant (sertraline) to see if a better response can be obtained. I have written extensively on behavior management in dementia in my book, "Long-Term Management of Dementia" (Informa healthcare publishers). 

Some individuals can have dental procedures that may allow for fixed bridges or the like. Discussion with her dentist is recommended regarding those options. Dentures are often misplaced or hidden by dementia patients. If in an institutional setting, engraving of dentures may help to identify whose dentures belong to whom. Also be sure to look for missing dentures in any device that holds water. We have found dentures in toilet tanks commonly. Also it may be most important to determine if the patient wants to wear the dentures. If she has no interest in the dentures and views them as some foreign object, than I would avoid using them at all. Individuals are still able to eat softer diets without needing teeth. If the family is concerned by appearance, than they may put the dentures in only when she has company. 

Forgetting names of relatives and their relationship is common with Alzheimer's disease patients. Confusing daughters with sisters is common as they live more in the past where his daughter was much younger and his sister was not yet passed. He may not be able to learn that this person is really his daughter and not someone else. If their relationship is pleasant, then it may not be so important to always get him back to reality which he would have a hard time believing. If he is suspicious of this daughter and wants her to leave or makes it unpleasant for him or her to be together, then treatment with medications to reduce his suspiciousness may be warranted. This may also help other significant false beliefs or suspiciousness. If medications are considered, low dose of quetiapine, ziparsidone or others may be considered by his physician.
 

Patients with Alzheimer's disease can develop many behavior symptoms including irritability, anxiousness, depression and false beliefs. These can be part of the disease. However, if there is some other active medical condition (urinary tract infection, pneumonia, drugs or drug interactions, significant heart, liver, or kidney disease, etc) going on, then there are often more sudden changers in behavior. The false belief of not recognizing family members as family members is called Capgras delusions. These false beliefs are best treated with atypical antipsychotic medications (like quetiapine and ziprasidone). If there are other concurrent medical issues, then those of course should also be treated. Increasing Prozac may possibly be contributing and since that was a recent medication change, I would consider lowering her dose back to 20 mg daily if agreeable by her doctor. 

If she does have Alzheimer's disease in the late stages, then music therapy will not help improve memory. However, singing with her is a great form of brain stimulation and is a pleasurable activity, both of which probably improve her quality of life. Songs known for a long time are longterm memories and are retained much longer than memory for recent events or learning new songs. Words that accompany songs are stored in a different place in the brain than regular words and are a form of automatic speech. She probably does not understand the words she is singing, but they go along with the melody.
 

There may not be much to do at this stage. She apparently has a good appetite, but is losing weight. Does she pace or move constantly so that she is metabolizing and exercising off all her calories? Sometimes a trial of mirtazapine can reduce over-restless activity and increase appetite. Other antidepressants may also help with restless activity. Might she have another process going on like cancer that can cause weight loss or does she have a lot of diarrhea that can reduce weight? Her weight loss is unlikely to level off if nothing is done since it has proven to steadily get worse over 3 years. I have had fair success stemming weight loss with the use of megestrol, giving at least 300 mg twice a day. It may be worth a try if she has no contraindications. Please check with her doctor. I do not know the answer to your last question but a dietitian may be one to ask.
 

There are a lot of questions I have regarding his clinical course of depression, dementia and Parkinson's disease. You seem to describe a rapid course. Is he more depressed or suicidal due to his nursing home placement? Has his difficulty talking been something new or gradually worsened? In regards to your question as to what can be done to get him to eat or take his medications, since he is in a nursing home with dementia expertise, they should be looking for ways to crush his medications, camouflage his medications into ice cream or pudding that he might eat or switch his medications to liquid formulations. Megestrol liquid 600 mg to 800 mg daily is helpful for many patients to improve appetite. Antidepressants may help if depression is the cause of his refusal to eat. Also consider increasing pleasurable activities or take him out of the facility for the afternoon if possible to be with friends or family. This case is very complicated and discussion with his doctor that has expertise in dementia is needed right away. 

I would refer you to a urologist specialist to look for other reasons for his recurrent UTIs and to suggest other choices for UTI prevention. It is unusual for males to get recurrent UTIs unless there are unique circumstances. 

If she is interested in knowing about her medical condition, there is no reason not to tell her. She will probably forget what you said soon enough and it is less likely to cause her significant anxiousness or depression. If she is not interested in knowning than you do not have to force it on her. You can ask her if she wants any details regarding her updated medical condition. This news is probably more uspetting to you than it would be to her.
 

Extended release galantamine (also known as Reminyl) comes in capsules that are filled with tiny pellets that are time released. When there is difficulty swallowing, it is usually easiest to open the capsule and sprinkle the pellets over food to make it simpler to consume. The gelatin capsule that contains the pellets is just a container and can be discarded if the contents are opened and sprinkled on food. It is not harmful or dangerous to chew the capsules or the pellets. However if some of the chewed pellets are crushed, they may lose their time release effect. Therefore it is best to sprinkle the contents onto pudding, yogurt, applesauce or other soft food so the contents are more easily swallowed without being chewed. 

Trazodone may be a good place to start. It is very safe and does not usually give any hang over effect. It does not make Alzheimer's patient's more confused. I usually start out at 50 mg nightly, but the dose can be raised up to 100 mg or even 150 mg nightly if initially not effective. If that is not helpful, zolpidem 5 mg or Ramelteon 8 mg may be useful. I would try to stay away from benzodiazepines like Restoril or antipsychotics like Haldol or Zyprexa for sleep issues as they can have other unwanted side effects. 

From the Parentgiving team: Based on the research that's been done, the simplest approach is using music from the person's past. Here's an excerpt from an article we ran:

How to make music therapy work
The Alzheimer’s Association recognizes the enriching benefits of music therapy. Music can stir long-term memories; and, best results may be obtained from music popular during the patient’s youth. Some patients might respond well to rhythm-and-blues or to instrumental hymns and spiritual songs. For the current crop of the over 80s, music from Glenn Miller and Lawrence Welk might be invaluable. Singing along or swaying or clapping hands with the music should be encouraged. Music therapy may awaken a desire to dance, which can be therapeutic. A patient’s enjoyment is typically increased as they move or sing with the music. Music therapy can also be linked to other memory-stirring activities such as looking at photographs.

The full article can be found at:
http://www.parentgiving.com/elder-care/music-as-a-tool-to-improve-communications-skills-in-alzheimers-patients/

This website also lists many of the published research papers on this topic:
http://people.uwec.edu/rasarla/research/alzheimers/unann_journal.htm#dancing
 

Individuals with Parkinson's disease dementia (as well as most other dementing conditions) often develop confusional states with changes in health, stress or environment. Medications can also be a cause of increased confusion, false beliefs or hallucinations. Medications for Parkinson's disease are often the cause of false beliefs (people killing people and beating him up) and hallucinations. This occurs much more often if the Parkinson's disease patient has dementia. Often these spells of confusion and agitation are transient.

The first thing to determine is if any new medications have been given to him or if he has been increased on any of his medications. Lowering his Parkinson's disease medications, if possible, may be very helpful. Keeping routines, familiar environments and familiar faces often help very much. At times, low doses of antipsychotic medications, like quetiapine, maybe useful for his false beliefs. It is also critical that he maintains good nutrition to help him recover more quickly. Supplementation of his meals with high calorie liquid supplements may be helpful in maintaining his weight.
 

His false belief of not believing that his home is not his home is a form of Capgras type delusion. The belief that his house has been duplicated and/or relocated to another site is called reduplicative paramnesia. Both are forms of misidentification syndromes. These type of false beliefs(delusions) can be seen in Alzheimer's disease patients. Head injury involving the right side of the brain and the frontal lobes may also cause this condition. It is nearly impossible to re-orient the individual as these thoughts are fixed. If the thoughts do not bother the person or others, then you can just empathize with their concerns. It is not typically helpful to disagree or try to correct as this often leads to agitation. If the false beliefs are bothersome, treatments with atypical antipsychotic medications often help the best. Low doses may be used. It is always a good idea to make sure he is not on other medications that may be a cause of these symptoms as well. 

For any dementia patient, the best care is given at places that specialize in that kind of care, like memory care facilities. Definitely consider moving your mother to such a place. 

Donepezil is the generic form for Aricept. They are the same medication. Since the dose is also the same, Donepezil should act the same as Aricept has done for her. I have not heard of any increased or different side effects when a person is given the generic form of Aricept. If she has tolerated Aricept without nosebleeds, my guess is that the Donepezil does not have anything to do with it. 

Individuals with Lewy Body Dementia often progress faster than those with Alzheimer's disease. Average life expectancy with Lewy Body Dementia varies with age, but is typically about 6 years. Some longer, some less. Most Alzheimer's disease patients live 8 to 12 years after diagnosis, also depending on their age of onset. Infections often cause confusion, and antibiotics that clear up infections may improve thinking. You would have to ask his doctor about the frequency of antibiotics. It depends on many factors that are patient-related. 

He has Capgras delusions. This is where he thinks that a familiar person (daughter) or place (home) is not their real daughter or home. First I would just try to empathize with his concern and tell him that it is getting late or cold or dark and that we can get him home the next day or find his daughter soon. If he does this excessively and it is causing him angst or he is attempting to wander away to find his home or daughter, it may be necessary to try pharmacotherapy with an antipsychotic medication. For Parkinson's disease, my first choice would be quetiapine at a low dose, maybe 25 mg, every evening prior to his behaviors. This could be titrated up to good effect if needed. Discuss with his physician if this is a good choice for him.
 

Behavioral disturbances are common with dementia and may include paranoia, suspiciousness, depression and irritability. Many times environmental changes or medications may help. At times it may be advisable to not contact her for a while as this may bring up the unpleasantness of her situation. However, if she is the one contacting you, then she could be more upset that no one responds to her. In that case, if she is in a high degree of angst over this, it may be best to consider behavioral medications. Often a selective serotonin reuptake inhibitor (SSRI) may help and they have very few side effects. If she shows a lot of false beliefs and suspiciousness, then an antipsychotic medication may be in order. Ask her physician what they may recommend. 

If prompting causes grief and argument than I would not prompt and instead just tell her the answer she seeks. If she has a lot of irritability then talk to her doctor about the use of an antidepressant such as citalopram or sertraline may be useful. They have very few side effects for most patients. If she has a diagnosis of Alzheimer's disease, check with her doctor to see if she is on the 9.5 mg/24 hour patch Exelon and Namenda to titrate up to 10 mg twice a day. 

Aricept and similar cholinesterase inhibitors usually will be useful for many years in those with Alzheimer's disease. It works very well in combination with Namenda. When the disease becomes vey severe, there is a point that these medications are not useful. That point varies a little bit from patient to patient and family to family. These medications will work less and less well as the disease progresses as there are fewer live nerve cells for them to work on. If your mother is no longer able to bathe, feed, dress or toilet herself and has little or no meaningful language abilities, then it may be time to stop the medications. If she still has meaningful function, then I would stay the course. 

There may be many factors that are paying a part in his decreased fluid and food intake. Very late stage dementia patients may "forget" how to eat or swallow. They are unable to correctly sequence the normal swallowing reflex and food does not get moved to the back of their throat to swallow. I am not sure your father is at that late stage. Other causes could include medication side effects. Is he on anything new since this problem has gotten worse? If you chronically do not take in enough fluids, you will be dehydrated, which often leads to increased confusion and poor food intake. If he has a tendency to choke on liquids he may not want to drink, and use of a thickening agent (ask his pharmacist for a recommendation) may help prevent choking. Use of softer foods or even puree may help with food intake. Food that does not need much chewing may be swallowed easier. 

It is impossible to comment on any specific individual situation as I do not have the background data to make any prediction. However, since there are changes in his behaviors and possibly cognition, I would get back to his neurologist to discuss prognosis. Sometimes medications, nighttime sleep issues or the disease itself can cause alertness issues. 

I am not sure what is causing the symptoms. However, I would follow back up with his neurologist. If they are at a loss than perhaps a second opinion by another neurologist would be advised. 

If she has incontinence, does she wear adult diapers? If not that may be an option for longer trips by car. Then it would be a matter of finding a restroom that you could lock the door or a unisex bathroom to change her Depends as needed. Sometimes you might try a medication to help retain urine in the bladder a bit longer. All of those medications will counter the effect of medications like Aricept or Exelon or galantamine commonly used for Alzheimer's disease. However, it may be worth it to give this medication only if traveling long distances and not at other times.
 

There are many behaviors that Alzheimer's disease patients may develop. Many can be helped with relatively safe medications or environmental modification. I would make sure he is taking his Aricept in the morning as that can cause sleep disturbance in some and may help activate more in the daytime. Sleep disturbance, not staying asleep, can be a big problem and can usually be aided by trazodone at night. Avoid Tylenol PM and like agents. Irritability during the day may be helped by anti-depressants and sertraline may be good for those that are more apathetic. It is wise to figure out if the cause of his irritability is due to any false beliefs as an antipsychotic treatment may work better in those cases. It is best to talk to his physician to see if any of these choices would work for him and his medical problems. Changes in the environment may also make life easier but it is hard to suggest what given the limited information I have.
 

Typically, most dementia patients have increased sedation and increased confusion after anesthesia. I'm glad to hear of your aunt's story but do not know what to make of it without knowing more about her medical history. 

Since I do not have any information on why he is on these medications, it is difficult to say if they are related or not. Did the yelling start just after one of these medications was added? Alzheimer's disease patients can yell out at times and there may be many causes. First changing the environment to reduce overstimulation may be useful. In some it can be a compulsive tendency (teated with high doses of antidepressants) or due to pain or suspiciousness or wanting attention and all of these may be treated in different ways. Explore with his doctor possible causes and solutions. 

Not recognizing family members is not uncommon in some dementia conditions. If you can reorient her to the fact that you are her son, it may help. Giving her a piece of paper that says your name and relationship to her may be helpful. If her advances are significant, medication therapy may be in order. Sometimes selective serotonin re-uptake inhibitors help reduce these type of symptoms. In severe cases, clomipramine may be helpful. I would further discuss with her doctor to come up with a management plan.

If you have a computer, there are a number of groups that list research opportunities and clinical trials for Alzheimer's disease. You could contact those research sites near where you live to see if you may qualify in any ongoing research:

ADEAR (Alzheimer’s Disease Education and Referral Center): www.nia.nih.gov/alzheimers
Agency for Healthcare Research and Quality: www.ahrq.gov
Alzheimer’s Disease Cooperative Study: www.adcs.org
Alzheimer’s Disease Neuroimaging Initiative: www.adni-info.org
Alzheimer Research Forum: www.alzforum.org
Alzheimer’s Resource Room: www.aoa.gov/alz
National Institute of Aging: www.nia.nih.gov
National Institute of Health (clinical trials link): www.clinicaltrials.gov

It is difficult to say why your husband may have balance issues. Many patients with a Parkinsonian dementia syndrome may get postural instability in that they are unable to maintain their center of balance for very long and will topple one way or the other. Of course, there may be issues with balance from inner ear problems, neuropathy, small strokes, brain lesions, nutritional deficiencies, endocrine problems, infections, heart problems, and diabetes, among many other causes.

The best method I know is to place your fingers inside their mouth on the side between their dentures and their cheek and pull them out. Be very careful not to get your fingers in the way of their teeth. In the short term, you can try brushing their dentures with them in their mouth. However, you will need to approach them again later and just take the dentures out for appropriate oral hygiene.

Stage 5 Parkinson's disease usually denotes the final stage where the individual is unable to assist with basic activities like dressing, bathing, feeding and toileting. They are at risk for infections like pneumonia and urinary track infections. They may develop difficulties eating as they may have trouble figuring out how to chew and swallow. Thick-It or other thickeners for thin liquids may help prevent gagging while drinking fluids and reduce the risk of getting the liquid into the lung causing aspiration pneumonia. Soft foods or puree foods are often required. Eventually they may be overwhelmed by an infection or just stop eating and drinking.

Yes. This could indicate early memory loss. I would encourage her to see her primary care physician as many conditions causing memory loss are treatable. I would ask her permission to share your concerns and observations with the primary care doctor or go with her to her appointment. The primary care provider can do simple testing to see if there is any concern.

Normally, if Alzheimer's is going to run in the family it will typically start about the same decade of life as the previous generation. Right now, we do not have treatments to prevent the accumulations of the toxic proteins that build up in the brains of Alzheimer's disease patients. Hopefully we will have such treatments in the future. Currently we only have symptomatic treatments which mean that these treatments are known to help only if the person has symptoms of significant memory loss or thinking problems. If you do not have such problems yet, the effectiveness of these symptomatic treatments are unproven and in studies shown not to be helpful. I would suggest a cognitive screening test to help identify the start of any memory or thinking issues that you may have. This test could be repeated periodically over time, maybe every couple of years, to watch for any declines.
 

As we get older, our brain also ages and most commonly we become slower in our thinking processes. We may become forgetful momentarily, but with a reminder we are back on track. The memory and thinking problems that arise with a condition like Alzheimer’s disease is distinctly different from that seen with normal aging. Alzheimer's disease causes trouble with encoding, or getting memories into storage. These individuals will ask the same question over and over as if they never asked it before. Reminders or clues do not help as much. The memory was never stored well to begin with. People with Alzheimer's also often have trouble with finding names of less frequently used objects. In normal aging vocabulary remains intact, although momentarily forgetting names of people is very common. Getting lost in a familiar area is not normal aging and could be a sign of Alzheimer's disease. Decreased insight is also common with Alzheimer's patients, as typically significant others will notice the memory and cognitive problems more than the individual. If you notice memory issues in yourself more than those who know you best, Alzheimer's disease is less likely.

Any time there is a change in a person's memory, thinking, functioning or behavior it is a sign of something affecting the brain. The first step is to get them into their primary care provider for an assessment. Many conditions affecting the brain are treatable and some are reversible. The treatments are most successful when they are started as early as possible. Do not put off an evaluation to see if things get worse. Health care providers will take a history, perform an examination and assess memory and thinking with pen and paper testing. If it is necessary lab testing and scans of the brain may be done. Having the correct diagnosis is critical in planning the next steps. After a diagnosis is made, appropriate treatments, provision for increased supervision needs and referral to any needed social agencies can be arranged.