Lucy-
As a psychiatrist I am concerned by the apparent arrogance of the
psychiatrist involved. Even if he is also a Board Certified
Neurologist (as opposed to being certified by the American Board of
Psychiatry and Neurology in Psychiatry) he is not the treating
neurologist and likely does not have expertise in movement disorders and
PD. If you send me his name (by direct e-mail) I will check his
qualifications in the AMA database. There appears to be a lot of
problems with communications with the apparent avoidance of at least
telephone contact.
Considering each of the parts of your story some random thoughts:
> During that time, dad's condition worsened to the point that he was
> suffering more severe hallucinations and extreme paranoia. He saw
> animals
> and people that didn't exist. He stopped sleeping. He believed that
> everyone
> was conspiring
> in a plot to injure him or take his home.
>
> As this situation worsened, I became more involved, and discussed his
> symptoms and medications in detail with his neuro and the temporary
> in-home
> caregiver. It turned out that dad had been given additional sinemet in
> error
> for several days. When his sinemet intake was stabilized, he improved,
> but
> only slightly.
>
> He became belligerent, increasingly irrational, and even frightening.
> Because of his paranoid behavior, my mother chose to forgo her own
> health
> needs and stopped all her in-home nursing care and physical therapy.
>
> We hoped that my father could be admitted to the Duke University
> Medical
> Center [where his neurologist is located - 50 miles away from us] for
> evaluation of his meds, as well as evaluation of his psychotic
> behavior.
>
> However, his neuro said dad could not be admitted unless there were an
> acute "medical emergency"--i.e., unable to breathe, unable to swallow,
> stroke, chest pains; any 'lesser' reasons would not be covered by
> dad's
> health insurance,
>
> He then suggested adjusting some medications over the phone. At first
> he
> recommended cutting back on the permax only - 1 at 09:00 a.m.; 1 at
> 2:00
> p.m.; 1/2 at 07:00 p.m. - an overall daily reduction from 1.00 to .63
> mcg.
> All other meds remained the same.
>
> When there was no improvement after 4-5 days, the neuro recommended
> stopping the Elavil at night, waiting 3 days, and then stopping the
> Eldepryl.
>
> However, before these changes could be made, the paranoid/delusional
> symptoms reached a critical point, and we felt he might be a danger to
> himself [and others].
It appears that the neurologist did not appreciate the level of danger
{Perceived by you}. If he did I think he would have been able to
justify a psychiatric admission if not a neuro admission to Duke
Hospital. The fact that he was (I presume) not on the staff of the
local hospital limits his ability to consult (for legal reasons). It
was the psychiatrist's responsibility to request info and case
coordination from the neurologist since the psychiatrist was the
attending MD during the hospitalization. By medical Protocol, it might
have been seen as interference for the neurologist to make the first
call. (But good care especially since you requested it!)
We had to have my dad involuntarily committed to
> the
> psychiatric ward of a local hospital.
>
> The psychiatrist there [who claimed to also be a board-certified
> neurologist] made quite a few changes in medication.
>
> He cut out the Eldepryl, the Permax, and the Elavil. He added
> Amantadine to
> the original Sinemet schedule; he added the antipsychotic Risperidone;
> he
> added the
> mood stablizer Gabapentin.
>
> He released my father within a week, claiming that his severe
> delusional/paranoid behavior was med-induced, and most certainly would
> be
> easily controlled with the changes he had made in meds.
I have no problem with the notion of attempting to decrease the PD meds
as a first step but the PD symptoms need to be monitored closely. I am
not familiar with the use of the anticonvulsant gabapentin in psychiatry
but other anticonvulsants are useful in mania. Rispiridone is a
reasonable first try antipsychotic but it does have some dopamine
blocking qualities and is likely to worsen PD symptoms especially when
other meds have been withdrawn.
>
> The psychiatrist did not consult with my dad's neurologist, although
> he had
> been asked to; and my dad's neurologist did not consult with the
> psychiatrist, although he had been asked to.
>
> Since dad was released from the hospital on July 10, his condition has
> shown some improvement.
>
> His hallucinations/delusions are milder; however, he continues to
> exhibit
> paranoid behavior; he has become almost zombie-like. His on-time is
> next to
> none; he literally falls on the floor and can't get up. He still stays
> awake nearly all night, talking constantly. He refuses to submit to
> in-home
> health care.
This was a likely complication. But what are you complaining about. The
psychiatrist helped your dad with his hallucinations. You want him able
to move too- How ungrateful.
>
> Within the last week, the psychiatrist has taken him completely off
> the
> Risperidone and the Gabapentin. My dad now takes only Sinemet [the
> original
> schedule] and Amantadine [100 mg. one time daily at 9:00 a.m.]. He
> also
> takes .05 Synthroid [for hypothyroidism] once daily at 9:00 a.m.
>
> My mother cannot care for him as she did prior to her surgery. We [my
> three
> brothers and I] have investigated local nursing homes, but they won't
> admit
> him to skilled health care because there is no acute medical
> emergency.
>
> I guess my questions are:
>
> How can I convince the neurologist and the psychiatrist to consult
> with each other?
It sounds like a lost cause. Are they refusing to do it or just not
doing it? It appears that they work in 2 different systems and it is
hard enough to get doctors together who are in the same group. I wonder
whether you inadvertently contributed to the lack of communication by
having him admitted in a hospital dads neurologist did not (I presume)
practice at.
>
> Why will his neuro not admit him to the hospital for evaluation unless
> there is an acute medical emergency?
Insurance will not pay for admission unless a valid case is made to them
that he meets admission criteria (which vary depending on the company.
You need to make the case to the neurologist that he is in serious
danger either medically or psychiatrically. Make it clear what you fear
will happen to him and give the doctor concrete examples and document
why you think he is unsafe to continue to adjust meds in the home
situation.
>
> Why will a nursing home not admit him for skilled health care unless
> there
> is an acute medical emergency?
I don't know what their criteria are!!
>
> If a man cannot care for himself, cannot walk, cannot feed himself,
> cannot
> dress himself, cannot clean himself, cannot get himself on or off the
> bed,
> and exhibits irrational, psychotic behavior, does this not constitute
> a
> medical emergency?
Yes!! Especially if it is an acute change as opposed to a chronic
unchanging condition. But you must document it.
Be assertive and good luck
keep us informed.
Charlie
--
CHARLES T. MEYER, M.D.
Middleton, WI
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