dad taking too many meds...HELP

just me · � #1 � 02-17-2008, 10:47 AM

Dad in law has been in a nursing home for over a year.... We switched to a new nursing home back in July when the doctor at the last nursing home prescribe potassium for swelling in his legs, and then dad almost died of renal failure....
So now, problem with the new nursing home.... massive amount of meds being given... Here is the list:
prilosec OTC 20mg
claritin 10 mg
Imdur 60 mg
hydrocodone/apap 7.5/750 mg discont on 1/31/08
zocor 10 mg
lopressor 50 mg
ferrous sulfate 325mg
coumadin 4 mg
lasix 80 mg
geodon 40 mg
med pass2.0 120 ml tid
neurontin 300 mg
ativan 1 mg (QHS)<what does QHS mean>
apap 325 mg
maalox
flagyl 500 mg tid <not sure of this spelling/ written by hand

Help me here guys.... I told them, that I didnot want him on the geodon.. Ive done the research of the Imdur, and he isnt suppose to be taking it because he has congestive heart failure.. I started searching on Zocor, and I know that it is debilitating to the muscles... and he has to get off that, but Im not finding the bad side effects written anywhere....
Right before Christmas, Dad was happy where he was at, was very cheerful and moving around... now he is a crying depressed mess, that cant even get out of bed on his own.... he has fallen out of his wheelchair three times, and has been sick since christmas..... I need help.. He called me this morning, and told me to come get him, because those people are being mean to him....He has more confusion, and is totally miserable.... please help.

Arrowwind09 · � #2 � 02-17-2008, 12:00 PM

prilosec - only use if he has chronic heart burn. If it is just once in a while use tums.

claritin 10 mg - does he have allergies? what time of year? only use if allergies are a current problem

Imdur 60 mg - he obviously has a cardiac condition. angina? chf? I wouldn't stop this either. Since this is a mild ace inhibitor it may be why he had potassium problems.

hydrocodone/apap 7.5/750 mg discont on 1/31/08 - well, this was discontinued. So he has no pain now?

zocor 10 mg - get off of this and provide cinnammon. one cap 2 x day should do it.

lopressor 50 mg this for blood pressure. I would not stop it. But make sure his BP is checked weekly. Dosage should be evaluated periodically

ferrous sulfate 325mg - is he anemic? Get him off of this and provide a plant based iron IF he is anemic. I late Nature Sunshine IX forumula

coumadin 4 mg - well, has he had a stroke, blood clot? Need more info on what and when

lasix 80 mg - Does he have CHF? Lasix is why he was put on potassium. Lasix makes you dump potassium. Its very rare that someone takes lasix and no potassium. Usually they are prescribed together.
Perhaps he could switch to the diuretic spironolactone as it reserves potasssium or do half and half of each. This is a pretty high dose of lasix and it tells me that his cardiac conditon is pretty severe. He's just not moving his fluids.I do not think you should be upset too much with the doc that prescribed potassium, unless his blood worked was not rechecked. You always need to do a CMP to make sure things are ok after changing meds like these. CMP will tell you generally how the kidneys are doing.

geodon 40 mg - this is for depressive disorder with a manic component.So whats up there? There must be a reason that they selected this particular anitdepressant.

med pass2.0 120 ml tid - this is crap. Provide a protien supplement that is actually good for you that delivers the same amount of protein. I guarantee that he is serum protein deficient and this will contribute to edema also. Has he actually been drinking it? They usually pass pills with it.

neurontin 300 mg - this is for various neurological pains that other pain meds can not seem to get too. I would not stop it if he is having that kind of pain.

ativan 1 mg (QHS)<what does QHS mean> HS means hour of sleep. Ativan is a sedative. They are giving it to him for sleep, likely due to anxiety or behaviors that keep him from sleeping. Doesn't ambien work? Its a better choice if it works. If not ativan is not the end of the world.

apap 325 mg - this is tylenol. I notice he has lortab also. both have tylenol. Make sure he is not getting too much tylenol. 4000 mg is permitted per day but I think 2000 is safer. How many lortab does he take a day and for what?

maalox - this is for heart burn. Perhaps he does have an acid reflux problem. In which case continue with the prilosec. Remember, he is not in a place to get healed. Comfort is what you should be thinking about.

flagyl 500 mg tid - this is usually for a fungal infection of some kind but it treats a variety of microbes. Where is it and when did he start this? This can cause nausea and fatigue. Does he have a urinary tract infection?

I wonder why your dad is not on Digoxin?

Does your dad still walk? Can he still make his own decisions?

just me · � #3 � 02-17-2008, 01:03 PM

Dad was walking when he went into the nursing home situation, but stopped walking that day... There are times when I think that yes he can make his own decisions, and then there are times when he is really confused.... He has fallen out of bed three times, just at this nursing home... (they are a restraint free facility, so dont have bed rails????) according to the nurses, he fell out because of confusion. His diagnosis according to these papers that I made copies of.... are:
chr airway obst
cholecystitis uns
renal failure nos
congestive heart failure
duodenal ulcer nos
general muscle weakness
acute ill defned cv disease

Im not sure what all that means...

He has heartburn when he uses sweet and low, while he was here, a lo carb diet and no sweet and lo stopped all heartburn problems
He doesnt have allergies, but in some of the reading today, one of these meds causes allergy like symptoms... just have to remember which one... Interesting reading about the imdur... it said that doctors would probably not prescribe imdur if you have congestive heart failure and that imdur might aggravate angina....
The geodon... Im throwing a fit about... I have told them that we have had problems with antideppressants in the past, causing anger, violence and more severe depression.... apparently they are giving him this, because when he was sick with pnumonia in december, he was coughing up alot of mucos, and was choking on it, so he got really agitated and afraid to go to sleep.... so they decided to put him on antianxiety meds.... he cant sleep at night, because he sleeps most of the day.... Im wondering if they have him on the nuerotin because of the pain he is feeling from the zocor.... butthe nuerotin side effects are scary!!!! Alot of these meds are probably contributing to his depression..... He has a toenail fungus... which I have told them to treat with the vicks... work wonders for me... but they wont even try it....
It irrates the tar out of me, that he went from no meds at all while living here... was able to treat everything with diet oils and supplements....and now he is on all these meds that are making him worse... they are talking about giving him more antideppressants, because all he does is cry..... Im at a loss!!!

Arrowwind09 · � #4 � 02-18-2008, 11:20 AM

Well, just me, I work with patients like this all the time.

You may have a hard time with my opinion but according to his diagnosis and his mental state my best advice to you would be to call a Hospice care company and get them involved. This will be paid for by medicare.

He sounds like he is really declining. You can try pulling him off of most or all of the meds but the outcome will be uncertain. Removing the cardiac meds will ultimately lead to either chest pain, increased edema, respiratory shortness of breath or an earlier decline or both. Some families choose to pull them off the meds and let a natural decline and death occur. Pain and other symptoms that may come up will be managed by the hospice nurse.

Depression under such circumstances is very difficult. If he is crying a lot, confused, falling out of bed, there is little quality of life. You have to ask yourself what would your dad want in such circumstance if he still had the power to make a reasonable decision. I am not familiar with the antidepressant that they are using as the doctors I work with don't use it. He sounds like cymbalta or paxil would be a good choice to me.

A hospice nurse will make sure that he is comfortable. She may be better at sifting through his symtoms than a regular nursing home floor nurse who has little understanding of the medical management of someone who is advancing towards death, and likely little time also. And if the place is anything like some of the nursing homes I've seen the changes being made are due to a nurses report on the phone and not from a visual exam from the physician. These nursing home docs and their nurse practitioners, in my opinion, generally are not very good in their telephone assessments, and sometimes not even in their face to face assessments. AND their interest is in keeping him alive as long as possible regardless of his suffering, as this facilitates a better paycheck.

He is most likely to have respiratory distress and agitation. The medications used for this are generally haldol and morphine. Ativan may also be used. Some Hospice docs use a few other meds but this is what we generally use. With these they should be able to keep him comfortable. I know this sounds scary, these meds, but please trust me on this one. I have been through this hundreds of times. He can be made to be comfortable. And often conscicous to the near end. That will depend on how his disease process proceeds and the quality of the attention from his hospice nurse.

And his disease process will proceed wether you stop the meds or not. Eventually most family members responsible for a loved one come to the point where they see the fruitlessness of continuing on.

The meds he is on now are artificially continuing his life. And this is well and good if there is some quality there. You will have to decide if you are his power of medical attorney.

You could take him off the meds and he may live for a while. But the disease process will continue.

Please understand that the dying process is not done in a week or two. This is a process that often starts months before it becomes obvious to the lay person. He could be having delusions and agitation which would require a more skilled assessment and medical management than the nursing home nurse generally knows how to do. If they won't use side rails you must insist that they get for him personal alarms, two of them to be clipped to his shirt so when he tries to get out of bed they will know it and come to his rescue. There is nothing worse that adding a broken hip or arm to his list of diagnosis.

Those places that do not use physical restraints use chemical restraints and thats a fact. If he is falling out of bed they are liable and you must tell them that you want to know their plan of care to prevent falls. If their plan of care is not working they must make adjustments until they find one that does work! They must work diligently until the problem is resolved. I once worked in a facilty that had beds with no side rails. With some problem patients we just got rid of the bed and put the mattress on the floor.,,hardly dignified. Chemical restraint is my first choice but you really have to have an attentive nurse and doctor to get it right. You don't want him to have an increased risk of falls from the meds. It is a balancing act to get it right.

My preference is side rails with personal alarms (also called tabs alarm) and proper psych medication. I really hate vest restraints but we do rarely use them until the patient is properly medically managed. In 4 years I have used them twice until medical management was acquired. They were used for not more than a day or so. I prefer one on one observation and we can do that with our hospice volunteers helping.

A hopice nurse will make sure that the nursing staff has access to the medications and in the right dosage and frequency. The hospice nurse will also guarantee more nursing visits as the need arises, hence better support for him, for you.

From what you have written I suspect that his time here will be limited and that he will easily qualify for hospice. This will bring another nurse into his care and another cna also so you can be sure that he gets good basic care that nursing homes are so lax about.

I have to ask? are they consulting with you or anyone in the family about med changes? How come they just put him on an antidepressant without consult. If your dad is confused he needs someone making medical decisions for him. It should not be left up to the doctor alone.

Has he had weight loss?

Xania · � #5 � 02-18-2008, 12:36 PM

Arrowwind _ your post is so clear and sensible and based on common sense. It is useful information for anyone who has an aging relative.

When I was nursing, a long time ago - we found that bed rails actually increased some patients' agitation - they felt too confined. If we put the mattress on the floor, these people were calmer, and much safer, however undignified!

I have to agree with your assessment of just me's f-i-l - it appears that the end of his life is coming closer now and comfort and safety are the prime considerations.
just me, we are thinking of you and praying for you and your f-i-l. Please keep us up to date on his care.

just me · � #6 � 02-18-2008, 03:28 PM

Arrowwind, I love your opinion and your comments... Dad has been ready to die for quite some time now... He believes his time on earth is finished, and is just waiting for God to take him home... His daily prayer is just that, let him die and go to heaven where his savior and wife are waiting for him....
We have argued with doctors galore, they all believe that because he is ready to go home, that he is depressed. Because he says he wants to die, according to them, he is depressed.... so they start putting him on meds.... Doctors are not consulting me about meds, they tell dad this is what he needs, and he says ok... then he tells me how he doesnt want to take all these meds. Last night, I told the nurses that I wanted him off the zocor, that they needed to start weaning him off the geodon, and that they need to find a different med for the nuerotin (any suggestions, its being used for nueropathy) I also told them that a low sugar diet isnt good enough, that it needed to be a lo carb/ diabetic diet. (im thinking about telling them that he is allergic to wheat and rice, wonder if that would help) Told them I wanted to see a better diet, so that they could put him back on the metformin instead of just letting him eat what he wants and then give him insulin shots... Also told them that I wanted him to have a probiotic... The flagyl is supposedly because of a bacterial yeast infection in the stomach.. This is a new one on me, asked why I wasnt told about this.
I put a call into his old doctor (the one he had before nursing home) He has patients in another nursing home, and he is head of the hospice program in our area... I am trying to find out if we switch him to this other nursing home, would this doctor work with me to get rid of most of the meds and give him some of his dignity back...
All dad wants, besides wanting to die, is to have someone beside him, someone who would go to bed with him, someone that he could wake up with....and I cant even give him that.. He is just lonely for the love of his wife.
Oh, I dont think dad needs to be restrained to the degree of a vest restraint, but bedrails so he doesnt fall out of bed would be nice... The first time he fell, he was apparently getting sick... He had vomited that morning, so according to what the nurses told me, and my daughter in law(who happened to go visit him that day) they were afraid that because of his lethargy, and confusion that if he started throwing up again, he would aspirate. So they made him sit up in a w/c... when my son and d-i-l got there, he was so totally asleep/out of it... that my son first thought he was dead. leaning forward in the w/c...my son said that they tried to wake him up, and he didnt respond at all to them... d-i-l said that she tried to tell the nurses that he needed to be put back to bed, and they told her that he needed to stay in the w/c... Needless to say, after they left, dad (according to the nursed) continued to ask to get in bed, and they told him no... so he tried to get in bed by himself... thats when he fell... My logic tells me, that if he is so lethargic that he could aspirate on his own vomit, then how is it safe to have him in a w/c without any type of restraint... and now, he has fallen out of the chair two other times, because of confusion... something isnt right with that.... he isnt being provide a safe environment in my opinion.... I really think its time to get him out of there.

Thank you both for the info and the good thoughts..... the nurse was surprised that I sounded like I knew what i was talking about.

Arrowwind09 · � #7 � 02-18-2008, 04:21 PM

Well, if the doctor does think that he is capable of making his own medication choices you better get in there right away and have your dad sign a medical power of attorney to put you in charge when he becomes incapable. Get it done now! Do not delay.

It sounds to me that the doctor is a dim wit if he thinks this man can make his own decisions. In the other nursing home, if that doctor is involved in hospice this is the best choice likely.

Now if this nursing home has its own hospice be careful. Some nursing homes do a hospice function but it is not done out of compassion. They will be stingy on the extra nursing assessments and visits from a cna. I would look around before making a decision. If they say the floor nurse will do the hospice work just say forget it and find your own hospice agency to assist you. Elicit the help of hospice volunteers to sit with your dad daily if possible.

Oh, I see, the doctor is not directly associated with the nursing home, he is a hospice director that has some patients in the nursing home. Good. That is OK. You can ask this hospice doc if they contract with the nursing home your dad is currently in. If the answer is yes Ask him which nursing home he thinks is best. Of course he will like the other nursing home better if thats the only one he has a contract with. Such is the way of the world.

Regarding insulin, in hospice, it is general policy when the patient reaches a certain level of decline or when the disease process is fairly certain that they will die in 6 months or less they really let go on the diet and insulin thing. Of course this is not forced on them but it generally is what hospice promotes and they will endeavor to educate in this direction to get family compliance and understanding, and in most, but of course not all cases, I think it is the right thing to do.

You have to ask yourself these questions. Why are people on insulin? What are you trying to prevent with insulin? One of the major issues in long term insulin use and diabetes in general is the prevention of decline of the vascular system, the organs in general, vascular disease, blindness. At the point that your dad is right now these are not big issues. They are big issues when you have 5 or 10 or 20 years or more ahead of you. You want to maintain the health of these body parts as best as possible and it is done with good sugar control through diet and the use of insulin.

So in hospice we usualy let the patient eat what they want when they want. We want them to enjoy food and not worry. We accept blood sugar levels around 200 as ok. We tend to do lantus at night and only if needed a sliding scale during the day to keep the blood sugar around 200 or so. Often we rarely check the blood sugar. Only if there are symptoms of a problem, hyper or hypoglycemic. Most generally these folks will stablize around 200, 250, and they get to eat what they enjoy in their last days. It takes a lot of pressure off of them, and best of all no more finger sticks.

If he is on neurontin for neuropathy it would be mistake to take him off of it if it is doing the job. It most times controls THIS KIND of pain the best. Other meds are not so good for neuropathy. Neuropathic pain can be severe. They just don't do the job neurontin can.

So in my opinion, your dad is not truly clinically depressed. He is having situational depression, which is normal. He sees his death approaching and has sadness, talks of dying which is normal, and perhaps some fears and other concerns that he no longer has the power to address. If there is some dementia, confusion, it makes it worse, hence the crying spells. This does not rule out an antidepressant. If he is crying a lot, very sad, can not change his world view or situation it is worth a try with an antidepressant. Geodon is for a manic/depressive disorder. It sounds like it could be the wrong one to me.

Hospice will see to it that he gets spiritual counsel of his choice, and frequently if needed. He needs to talk to someone who is not denying his sitiuation, like his doctor is. Remember, the longer he lives the better the paycheck for that doc and the nursing home facility. Hospice always supports and provides chaplain care, makes phone calls to get the right people in for spiritual work.

In regard to having to sit in a wc until he falls over. THIS IS ABUSIVE!
Why not just put the head of the bed up. He's not going to aspirate if he's not eating or drinking. Sheeesh.... When he is eating and drinking aspiration precautions should be inacted by the nurse or cna. Thickened liquids, pureed or soft diet. eat slowly, chin tuck if he can manage it, head of the bed up.

Oh, there was nausea. Did they treat him for nausea? or just make him sit in a chair for a few hours. You see, a couple doses of haldol and the vomiting would be gone and he would rest peacefully, (in bed) but only hospice will use haldol in this capacity. Haldol will get rid of nausea, treats agitation and pyschosis. It is a great drug when used correctly. Most people do not realize that psychosis is a fairly frequent symptom in the dying process and many many people get it who never had a bad mental day in their whole life! I think it is caused by system failures, toxicity, You did say he had kidney failure, so there you have it.

Side rails are sometimes considered less safe than no rails according to studies done. I think that largely depends on the faciltiy and type of patient. We use them and don't have much of a problem. Most of our patients are too weak to climb over them yet still strong enough to fall out of bed. We also have a good nurse to patient ratio. I average 6 patients a day and I have a cna also. We make hands on contact with a patient every hour, either I or my CNA. This is what reduces the risk of falling the best. We also use a lot of alarms.

Ask your hospice doc if there is an inpatient hospice in your area. He seems like he could qualify for GIP status. On GIP status you will not have to pay for room and board and he will get acute symptom management care. Medicare will pay. When he is stable he will return to routine classification of hospice and you pay room and board again, but the hospice nurse coverage and cnas, hospice meds, etc will remain paid for by medicare. You tell him that. See what he says... You can bring him to where I work! We were awarded best in State for Nursing and Alternative Medicine 3 years in a row!

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