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Old 04-14-2009, 11:54 AM   #1
perriwinkleblue
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Any PT's or geriatric nurses out there? Urgent question about DM...

Please forgive me if I ramble, but my question is regarding PT rehab for my elderly mother and I'll try to explain the situation as best I can.

Background: My elderly mother may have had mild dementia for a couple of years (even her PCP thought it was too early to call it Alzheimer's) but was fairly "normal" and could converse with others and care for herself. She had no prior mental health issues. At the beginning of February her behavior began to get bizarre and this led her to spend time in the hospital for a delirious episode (of unknown cause, possibly UTI or an infection). She was treated like a geriatric psych patient and I don't think anyone believed us when we told them how quickly her mental condition had changed.

Prior to this event she was independent and walked with a cane but she has severe osteo arthritis in her hips and knees. (she loves Disney and used a wheelchair for trips) During her hospital stay she was confined to a wheelchair and was rarely ambulated although at the beginning of her stay she could stand.

At discharge, she went to a rehab/nursing facility to regain mobility (her confusion has persisted.) At the rehab, she was diagnosed with septic arthritis in her knee due to a staph infection . She may have had this in the hospital and it was not diagnosed (we were very disappointed with the care she received) or she may have picked it up there when they drained her knee because of fluid - but either way, she had this infection for at least a week before it was detected and treated! My question is this: is it uncommon for a septic arthritis patient to have trouble standing? She does not seem to be able to lift herself from sitting and when assisted, does not bear weight on her knees (she keeps them bent).

The PT thinks she has "plateaued" because she is unwilling or too demented to stand. She will be discharged from the rehab based on this assessment. The PT doesn't believe that my mother has any pain in her septic knee. I have tried to help her stand myself and she appears to be trying (she bears down on supports with her arms and seems stressed by the effort). When I ask her, she tells me she can't do it but will try later. It seems that after she refuses to stand her PT session ends and she is returned to her room.

If it factors in, she is diabetic and is still taking the risperdal and Depakot that was prescribed for the delirium. Also, she now has non-pitting edema of both legs and feet and her calfs are swollen and rock-hard.

I believe she should not be written off and could still benefit from PT. At the very least, I believe that the septic arthritis and edema should be considered. Something does not seem right here. She is a very sweet lady and I am so frightened for her. I thought that maybe some of the good souls on the Dis might be helpful? What is your opinion? What can I do to help her?
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Old 04-14-2009, 08:12 PM   #2
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Sorry to hear about your mother. Dementia is a horrible disease.

Are they treating her edema with any diuretic? Does your mother have any history of heart disease? Have her blood sugars been within normal limits?

If her dementia has suddenly progressed like you say it has PT will not be able to work with her. The big thing in PT is that the patient has to be able to fully participate and comprehend the treatment. If she does not then there really is no point to worry about the PT at this time. Sorry.

The best thing to do is to follow up with her PCP and address the issues above along with your concern about her having pain.

I saw you mention a UTI did they actually diagnose and treat her for one?

I hope all works out and you find the help for your mother that you seek.
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Old 04-14-2009, 11:44 PM   #3
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Thank you for your response. She has not had any heart disease. Her blood sugar was "okay" (she takes glimeride). She never had edema before but it started at home at the onset of her behavior change (before she was wheelchair bound). Her blood pressure was high in the hospital and her heart rate seemed high to me - considering she was in a near stupor. Her blood pressure was always low normal before. (An unusual thing that accompanied this behavior change is that she was always insanely hungry: trying to eat anything and everything - all the time. She still is obsessing about food - ??)

She did have a UTI and was about 2 days into treatment when she went to the ER. The staph infection is currently being treated with two oral antibiotics.

The dementia diagnosis has been the hardest to deal with. It's so hard to accept that just a few months ago my DM functioned well, cared for herself and could carry on a normal conversation - and now doesn't make much sense and can not walk. This change happened over the course of a week or so - getting worse by the day. She lives with us and I witnessed the swiftness of her decline and it was dramatic.

I've read that delirium can persist in the elderly. My nagging worry is that IF she is suffering from "early" stage dementia and ALSO the effects of delirium it may be worth trying to regain some mobility. Your comments do help me to understand where the PT is coming from. Would they maybe still try to work her joints to preserve muscle? She seems to have trouble bearing weight on her knees and I believe she has pain/fear and is unwilling to "work through it" as you or I would. She participates in games and chair exercises that are offered.
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Old 04-15-2009, 04:08 AM   #4
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Yes PT can establish what they call a restorative program for your mom. They can teach you what type of exercises to do with her, usually passively, to help muscle wasting.

At what stage of the dementia is your mother now at? Has her PCP seen her since the hospitalization?
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Old 04-15-2009, 08:49 AM   #5
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Your Mom is very fortunate to have you as her advocate. It does make a difference when the medical staff knows that someone is overseeing their elderly loved one's care.

My own Mom battled a staph infection that was more pervasive than your Mom's. It was very painful and left her extremely weak. Based on what my DM went through, it is possible that your Mom's pain is real.

I know that you're feeling helpless and frustrated. I'm very sorry that you're going through this.
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Old 04-15-2009, 09:28 AM   #6
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I do not know what stage she is in. The whole dementia diagnosis is really new to me. Her PCP has not seen her - only the nursing home doctor. I feel that because her baseline state prior to her hospital admission was so different, they almost don't believe us. She showered, dressed, ate, visited the senior center, socialized with friends, etc - all independently... That's why I wonder if delirium could be factoring in. She is 83.

Within days she became incontinent and could not figure out how to dress herself - at all. She started saying really weird things and could not hold onto a thread of conversation for more than a couple of seconds. She seems to have lost all grip on reality although she remembers us, her age, popular songs, her birthday etc.

We have a care-plan meeting today and she has an appointment with an orthopedist tomorrow. It was my wish to have her come home but I can not lift her and my home is a ranch - I doubt a wheelchair could make it around the corners. It breaks my heart and I do feel helpless and frustrated. She is not just my mom but was also my friend, we feel such a void with her not here. I want to make sure I do all I can do for her.
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Old 04-16-2009, 11:04 PM   #7
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Quote:
Originally Posted by perriwinkleblue
My elderly mother may have had mild dementia for a couple of years (even her PCP thought it was too early to call it Alzheimer's) but was fairly "normal" and could converse with others and care for herself. She had no prior mental health issues. At the beginning of February her behavior began to get bizarre and this led her to spend time in the hospital for a delirious episode (of unknown cause, possibly UTI or an infection). She was treated like a geriatric psych patient and I don't think anyone believed us when we told them how quickly her mental condition had changed.
I'm sorry to hear about your mother.

Did they do a head CT or other studies at that time to rule out stroke, micro-strokes, or any other type of acute neurological issue?

Has she ever had cognitive testing?
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Old 04-16-2009, 11:35 PM   #8
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I would strongly recommend seeking out a good geriatrician to evaluate her. The UTI certainly could have thrown her into a delirium that has not resolved with all the subsequent health issues that she has suffered. I would also suggest a neuropsycho evaluation to assess the dementia. A CT scan would probably be a good idea which I'm sure a geriatrician & neuropsychologist would request. A CT scan would be helpful in determining if she has multiinfarct dementia. Another question would be is she experiencing a depression which in the elderly can manifest itself in dementia--difficult to treat in the elderly related to their sensitivities to meds. Again a neuropsychologist could be helpful in evaluating this.
PT in a rehab setting has to be more aggressive. Have you considered bringing her home and requesting Home Health with PT & OT at home? Rather than daily PT at a rehab facility, PT would come to the house three or four times during the week to work with her and instruct family how to work with her in between times. Good luck.
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Old 05-05-2009, 07:59 PM   #9
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Quote:
Originally Posted by perriwinkleblue View Post
She did have a UTI and was about 2 days into treatment when she went to the ER.
Quote:
Originally Posted by Lady SnowElla View Post
I would strongly recommend seeking out a good geriatrician to evaluate her. The UTI certainly could have thrown her into a delirium that has not resolved with all the subsequent health issues that she has suffered.
I discovered last summer with my dad (88) that a UTI can be very, very serious in an older person sometimes radically changing their behaviour patterns. It is not always permanent.

My dad was in the hospital for the UTI and then was sent to a rehab center (much like a nursing home) for a few days. Because they were afraid of falls he was not allowed to get out of bed except to get in a wheel chair - and some limited rehab.

Rehab kicked him out afterabout 4 days - against the wishes of his doctor. In my opinion the rehab doctor just was clearing beds before a holiday weekend.

It is almost a year later. My dad's brain is sharp as a tack again. He is still frail and weak. He gets tired very easily. But he can actually take care of his own personal hygiene - and he's back in the kitchen cooking up a storm from his stool.

Good luck.
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Old 06-29-2009, 08:36 AM   #10
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Hi,
I am an out-patient PT and have seen UTI and other infections drastically change a patients status. You will need to keep pushing for a full evaluation. Has anyone checked her back and spine? There could be an infection there that is affecting the nerves to her legs. Good Luck
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Old 07-02-2009, 11:04 AM   #11
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I just want to send thoughts your way
My mom deals with similar situations and like another pp said, she is very fortunate to have you as her advocate. It may get exhausting at times, but what you are doing for her is wonderful.
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