Reflections on a Geriatric Psychiatry Unit
I have been working long hours on a Geriatric psychiatry unit at a local hospital where ninety percent of my patients are suffering from dementia. Lost in a world that they are sometimes in and sometimes out of. The decision makers in their families are put in difficult positions. Suddenly the children are taking care of their elderly adult parents who cannot speak for themselves. Be kind to your children because they may be taking care of you when you are old.
Like Bruce's son. Bruce who is a widower was forgetting where he was all the time. He lived alone in Maine all of his life, but he would arrive at a destination, still driving at 90, and not know how he ended up there. He would call his son Eddy in Massachusetts and cry profusely, expressing how he hated his life in Maine. Bruce, a pleasant old man who reminds me of Jimmy Durante, tells me a different story, a very romantic version of how he would walk along the boardwalk daily and stroll with his friends. Bruce tells me he had many friends, some of whom have died. That is how he remembers it. A beautiful scene, walking in the sand and talking to his friend.
He says, "I just want to go back to Maine, I don't understand why I am here, in this place. I feel like a prisoner." Bruce is right, he is locked on an inpatient unit where there is little light and little outdoor space.
His 45 year old son remembers it this way. "He would call me, almost everyday...crying that he had no friends, that he was very lonely and afraid...So I brought him here and now he still cries every day and asks me to take him back home."
The son is distraught and at a loss. He has just sold the only house his father ever knew. Bruce keeps asking to go home back to Maine, to his house on the beach.
'Did you tell him you sold the house?' I ask.
"No, I don't want him to know. He will forget about it anyway. "
"But you must tell him the truth, I insist."
His son responds "What's the point, he will forget anyway..." I tell him there is a part of Bruce that remembers and you must tell him the truth, in some sense he will know. Somehow it seemed to me that was the right thing to do.
Dementia is a funny thing, there are moments when lucidity exists and moments when it doesn't. I tell his son, medications will not take away the crying and the grief that your father feels. He is very much aware he is losing his memory and his brain is not functioning the way it was. Bruce tells me this everyday. That must be a painful reality for Bruce, to me it must feel like being swallowed up in quicksand and not knowing how to escape. The medications will only numb him for awhile and I prefer not to do that. The son replies, "a little numbing won't hurt him, it may help." I remain conflicted.
It is my feeling that the medications that we give, sometimes do more harm than good. In the case of dementia, antidepressants and antipsychotics do nothing more than numb the brain that is already vulnerable. As a matter of fact, we know that the antipsychotics that we prescribe for agitation in the elderly actually hasten morbidity and mortality. But they are often used. We know that the antidepressants may cause activation in some elderly people as well. The activation that got Bruce admitted to the inpatient psychiatric unit began when he had been on an antidepressant for 15 days. He became disoriented and started rummaging through other people's possessions and not sleeping at night, he became agitated and violent. He was actually admitted due to adverse effects of a medication. So the family sees Bruce as depressed because he is crying and I say he is crying knowing that he is losing the person he once knew. He is watching his memory being swallowed up in a vacuous hole to nowhere. A little numbing may help? I don't think so.
*The names and the identity of the patients are protected. This story is based on a merging of a few cases and does not represent a particular individual or case.