81 Year Old Has been Dx'd with Bipolar and Dementia - Advice?
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Q:  81 Year Old Has been Dx'd with Bipolar and Dementia - Advice?

Dr. Phelps,

My mother is 81 years old and has dementia. Her mother and her mother's mother had dementia.

My mother was diagnosed with manic depression/bipolar some years back. She has gone through so many meds I can't begin to tell you all of them.  

Don't know what to do now, treat dementia or bipolar.  It's so frustrating, because  she constantly has a problem with her eyes, sleep, itching, her nerves---- what do we do? What doctor will help? My Dad is having a hard time, because he is with her up and down at night. Their funds are very limited. Is there a reseach center that would help? I would be willing to work with them also, because I too could get dememtia and or have some of her same mental issues and not realize it.   

Any advise would be appreciated. Thanks for your time.

 Dear Lee --
Thatís a tough one, trying to sort out bipolar disorder symptoms from dementia.  As you may have learned, there is a great deal of overlap between the two conditions, including symptoms like agitation, insomnia, irritability, paranoia, and depression. 

I think most geriatric psychiatrists cleave to two rules under these circumstances: first, make sure that none of the medications already under way could possibly be contributing to those symptoms.  That's tricky, because many medications, even antibiotics sometimes, can cause mood or thought problems.  But if they have been there a long time with no prior evidence that they are causing trouble, that helps a little.  By contrast, a medication headed recently, an associated in time with a clear worsening -- obviously not one is more concerning. 

If a medication might be guilty (my favorite culprit to look for is an antidepressant), then of course it is always better to try to solve a problem by gradually removing a medication rather than by adding new ones. 

On the other hand, sometimes the situation can be so out of control, there really isn't time for that kind of systematic subtraction.  One has to jump in and treat the most problematic symptom.  In that case, it may not matter much whether the presumed basis for the symptom is bipolar disorder or dementia; one simply proceeds to treat that target symptom. 

As you have probably learned, many of the medications that we use for bipolar disorder are often commonly used for symptom control in dementia.  In my view, divalproex (Depakote) is underappreciated in this role, and in this particular setting (bipolar versus dementia or both). Likewise I think many of my colleagues and I have discovered that low- dose risperidone can be quite helpful.  (Once the dose goes over about 1 mg, however, there is a risk of chasing one's tail: at higher doses, this medication can cause muscle stiffness, can be relieved with a low dose of an anti-cholinergic medication, but the latter can make dementia worse.)  Both of these medications are now generic and might be considerably less expensive than many of the alternatives. 

The second rule of geriatric psychiatry: "start low and go slow".  That one always gets hauled into play. But the problem there is the same: if the situation is really out of control, it is hard to be patient and tiptoe up slowly on the dose.  Then one ends up trying to walk the fine line between being aggressive in getting symptoms under control versus trying to stay conservative and not at additional risk.  Very tricky sometimes.  That is where the helpful family member like you can sometimes play a useful role, giving information to the treating physician as to where exactly things are, as she/he tries to strike that balance; and interpreting the wishes/preferences of your parents in terms of how aggressive war conservative they might wish the physician to be. 

As for you, there are many factors that affect the risk of dementia.  But as you may have learned, many of the basic steps toward good health that everyone needs to take appeared to lower one's risk of developing dementia as well: prudent diet, regular sleep, regular exercise.  I hope that the situation with your parents comes under control quickly enough that you can keep these basic steps underway for yourself.  Good luck with the process -- 

Dr. Phelps


Published February, 2010


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