Hospitalization and Frailty

Maureen in the afternoon sun

Aside from the two times she gave birth, my mother has never had to stay in a hospital. She has had cataract surgery, Mohs surgery for skin cancers, and she has been treated in an emergency room and in an urgent care facility, but as of this week, she has never been hospitalized overnight for illness. Now that she has Alzheimer’s, I have dreaded the possibility of having to either call an ambulance, or admit her to a hospital, as I feared the resulting anxiety and disorientation would be more debilitating than whatever affliction might befall her. So last weekend when she began to have serious rectal bleeding, I made a round of phone calls and found that my anesthesia doctor from my recent ankle surgery was also practicing geriatric medicine and could do a house call that same afternoon. Imagine that! 

He immediately had me suspend four of her medications. Two were her Alzheimer’s medications, donepezil and memantine, here in Italy known as Aricept and Ebixa. For some time I had suspected they were doing more damage than good. In fact I recently read that memantine and donepezil should not be taken together, and not by patients with heart conditions. My mother has both high blood pressure and a heart arrhythmia. Donepezil is also bad for people with asthma, which my mother has had all her life. The other drug was warfarin, which thins the blood to presumably prevent strokes and heart attacks, but it carries a risky potential for causing internal bleeding. We agreed that hospitalization was not yet necessary, and might make matters worse for her. When her symptoms persisted the next day, he had her admitted to a private hospital not far from where we live.

Her hemoglobin was dangerously low, so she was given blood and plasma transfusions in order to prepare her for a diagnostic endoscopy and colonoscopy the following day. Thankfully with the help of some fantastic nurses, I got her through the prep and we had generally good news from the procedures: no tumors, no hemorrhoids, no need for any surgery. However, she had diverticulitis, and the working hypothesis was that her worsening anemia coupled with the impact of that cocktail of medications caused internal bleeding that eventually led to the hemorrhaging. Luckily a careful diet can help the intestinal healing, and now we will work to figure out how to improve her heart and lung health. 

I imagine readers of this blog are well aware of the dubious results of these two widely prescribed Alzheimer’s medications, and of the many undesirable side effects. Dr. Dale Bredesen whose work I have previously written about, posted on his Facebook page about a year ago about a meta analysis:

a recent study showed that patients treated with standard Alzheimer’s drugs donepezil (Aricept) or memantine (Namenda) actually declined more rapidly than those who were not treated with those drugs (Kennedy et al., JAMA Network Open. 2018;1(7):e184080. doi:10.1001/jamanetworkopen.2018.4080

What may be less understood by caretakers and even medical professionals is how the frailty of old age can mean unseen vulnerability that is not diagnosed with typical bloodwork and routine doctor visits. I think of myself as a pretty well-informed caretaker, someone who has done a lot of reading about Alzheimer’s, but I did not go to medical school, so I put a great deal of trust in doctors. When I saw symptoms like nighttime coughing, complaints of feeling cold, rising creatinine levels, increased sleepiness, breathlessness with fatigue, I did not pursue the possible reasons, even though I wondered about the medicines that negatively impacted kidney function. My mother’s doctor most recently diagnosed a flair up of asthma and prescribed prednisone, and it reassured me the chest x-ray showed no change from the previous one and therefore she felt the heart was not to blame for her symptoms. In retrospect, I am shocked that a simple online search turned up the fact that iron-deficiency anemia (which my mother has been taking iron supplements for since late fall) is almost always due to blood loss, and a simple test can determine if there is blood in the stomach or bowels. 

Lessons learned the hard way always leave a residue of guilt. I am grateful for the happy outcome of the procedure, for a trustworthy and competent doctor and his colleagues at the hospital, and for a mother who is a stubborn warrior and even in her most distressed state was willing to fight through it. I am more skeptical than before all this happened about the medical establishment, which seems even more dysfunctional than the really messed up field of education that has been my life's work. I see disturbing parallels. We know from replicable and reliable research that these medications are not working and are even dangerous, yet millions continue to take them in the hope they'll do something for their loved ones. We know that the toxic testing culture taking over educational settings is not improving learning outcomes and is actually harmful to students and teachers, yet we persist in ranking, sorting, praising and publicly humiliating people. We have a long way to go. We're not getting younger, and most of us are not getting healthier. Or for that matter, smarter. 

How We Sleep

We sleep like rocks, Roman ruins.

That was what I said in a Facebook post to friends in the first week of living in our Roman apartment. Anyone who has gone through a period of sleep deprivation or worse, insomnia, can attest to the restorative power of getting a good night’s sleep.

Sleeping Hermaphroditos, a Roman marble restored
by Gian Lorenzo Bernini in 1620 by adding a
marble mattress. Paris, Louvre Museum. 

I got interested in sleep science a long time ago when I was part of a sleep deprivation study at the University of Washington, where I had been temping in a women’s health office. Someone had dropped out of a three-day study looking at thermoregulation and it paid pretty well, plus did not involve any drugs, so I agreed to participate. The researchers were trying to figure out how new mothers, suffering from sleep deprivation, also had thermoregulation problems that could be quite acute. They had rigged a way to measure thermoregulation using a sort of shower system that took subjects from sweating to shivering by altering water temperature, and needed three days to test because subjects had to forego a whole night’s sleep between tests two and three. I didn’t need to see the published results to know that I had a much shorter time between sweating and shivering on day three after no sleep. The whole thing fascinated me.

One benefit of moving to a new place with no furniture is getting to start over. I knew that mattress technology had improved a lot since the last time I bought a bed, so I did a bit of research and decided to splurge on new mattresses from Eve, a UK-based company that shipped their high-tech foam mattresses in a box and gave you a 100 days to try them out. I was sold after the first night. In fact, I continue to be amazed at how well I sleep on this mattress, but I don’t want to turn this into an infomercial. Suffice it to say, proper support for the body and head (pillows matter too) make a difference in how we sleep and how well-rested we feel. My mother has radicular pain in her neck that had recently required physical therapy and medication, and she has been able to stop the pain meds altogether. 

My cat Mimi sleeps with me and
during the day likes to nap under
the covers, right in the middle of the bed.

It has been claimed that there is nothing that will prevent, delay, or reverse Alzheimer’s disease. Most of the mainstream medical establishment is focused on diagnosis and treatment of disease, and limits attention to matters of general wellness to stating the obvious. For example, the California clinical care guidelines for Alzheimer’s Disease give hardly any space to issues of healthy living, and only suggest that lifestyle modifications may lower risks and help the brain.

In her latest book and personal crusade to enlighten the public on the worsening sleep deprivation crisis, Arianna Huffington documents new findings from research that show the benefits of sufficient sleep to brain functionality, what she describes as “memory consolidation, brain and neurochemical cleansing, and cognitive maintenance.” Certainly for those with compromised brain health, these benefits are even more vital. Dr. Gregg D. Jacobs, a renowned advocate for Cognitive Behavioral Therapy to cure insomnia, warns that commonly prescribed medications such as Lunesta and Ambien have risks including elevated mortality for long-term use and are only mildly effective. I shudder to think what Alzheimer’s patients, already dealing with sleep disruption side-effects from Aricept and Namenda, do to themselves if they add insomnia medication. I only recently read that the vivid nightmares can be mitigated by taking Alzheimer meds earlier in the day instead of before bedtime. It’s no wonder that people turn to online forums for suggestions and advice in the absence of clear medical guidance.

One doctor’s blog called Eating Academy that I have been following since my own health issues in the past few years, provides an important source of health information that will soon be revamped into a book and website, peterattiamd.com. Sleep and recovery, what Dr. Attia calls “sleep hygiene” require a deliberate effort, especially as technology alters our habits and routines in ways that may have important consequences for health and wellness. In this post he shares how movement, and preparing the body for a workout, are crucial aspects of maintaining the body and being free of pain. I find his arguments and explanations to be very helpful and enlightening.

 There’s no clear number of hours of sleep we need for optimal health, although some argue evidence points to seven as the magic number. All I know is, we are now sleeping better than before, and we wake up pain free. We are lucky to have plenty of Roman sunshine to start the morning off on the right track, although a grey cloudy morning has its own kind of beauty too.