Please talk me down!

Nurses General Nursing

Published

Ok, facts first.

Mom and Dad are each 87 yo and live (seperately) in a care facility. He is on the Alzheimers lock down unit. She is on the floor that is one step down from lock down.

Mom has Parkinson's, NPH, multiple strokes, can't walk, nearly blind, she is depressed, what a surprise. The "house" doctor took her from 37.5mg daily of a serotonin/norepinephrine reuptake inhibitor to 300mg daily divided into 2 doses. No incrementing, just bump it up. We were unaware of the rx change until Mom landed in ED for dehydration, anorexia, and ALOC.

I called and left a message, actually telling this doc that I was taking Mom off of the docs service and would make other arrangements. When the doc called me back, it was as if I had never said anything about it. Doc just wanted to discuss the Rx I was concerned about.

When I asked the doc about the antidepressant bump, first I was told, 'I never prescribed it that way.' Okay, it was a verbal order, maybe there was an error. Later in the conversation the doc told me, 'well, that is an acceptable dosage for an adult.'

All of the info I have read indicates that this antidepressant should be incremented and used carefully in geriatric patients.

I did acknowledge to the doc that I had no proof that the Rx change had anything to do with the ALOC, anorexia, etc.. I asked if the doc was sure that the change had no detrimental effects, no answer. Doc did offer to prescribe Megace or something else that would enhance appetite, I pointed out that doc had prescribed Megace a month ago.

I know that the Docs have many pts and dont know the details for each one, however, am I just being a b*t*h here? I have not met this doc face to face. Doc cant tell me what the schedule is for rounds at the care facility so we could meet there. Please tell me if I am overreacting.

Thanks for letting me vent, your feedback is truly apprecitated.

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Specializes in Adult Stem Cell/Oncology.

No, you are definitely not being a b%#$!!! You are being an advocate for your mom, and thank goodness she has you there to look out for her! The doctor took her from 37.5 mg to 300 mg per day??? I haven't even started nursing school yet, but that sounds dangerous! I happen to take a SSRI (Paxil CR) for anxiety, and I know that you're supposed to gradually increase the dosage, and conversely, gradually decrease/taper off the dosage for someone going off the drug. I've also heard that elderly patients metabolize drugs more slowly and should be on lower doses of certain drugs such as SSRIs..... Again, not a nurse here, but 300 mg sounds like a huge dose! And if your mom is depressed due to her declining health and loneliness, no amount of drugs is going to "cure" her!

Does the facility have volunteers that visit patients? Pet therapy dogs that come visit? It sounds like your mom needs a big hug, so next time you see her, give her a big hug for me! :redbeathe

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Specializes in ER.

For Effexor, for example 37.5 mg sounds low, and 300mg sounds too high. It comes in both doseages.

From the website;

"Effexor XR is available in different dosage strengths (37.5 mg, 75 mg, and 150 mg). It can be prescribed in various combinations as necessary and as determined by your health care professional. The usual starting dose is 75 mg for depression, generalized anxiety order (GAD), and social anxiety disorder (SAD). The usual starting dose is 37.5 mg for panic disorder"

OK, I thought you were overreacting but after some research (if you mean Effexor) the side effects coincide with the symptoms you describe. Taking her off it altogether seems like a bad idea too- can you taper down a bit first?

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Specializes in Med-Surg, ER.
The doctor took her from 37.5 mg to 300 mg per day??? I haven't even started nursing school yet, but that sounds dangerous! I happen to take a SSRI (Paxil CR) for anxiety, and I know that you're supposed to gradually increase the dosage, and conversely, gradually decrease/taper off the dosage for someone going off the drug. I've also heard that elderly patients metabolize drugs more slowly and should be on lower doses of certain drugs such as SSRIs..... Again, not a nurse here, but 300 mg sounds like a huge dose!

As a word of caution, be careful about thinking about medications in terms of what "sounds like a big dose." Use a nursing drug reference and study individual medications. Every drug is different. Take metformin and glyburide for example. One has a common dosing of 2000mg/day. The other is 20mg/day. Both treat the same condition, but are very different chemically.

Given the info provided, I'll start by assuming the drug in question is venlafaxine (Effexor), a very common SNRI. It comes in the 37.5mg dosage. A dose of 300 mg divided bid is not out of the question - studies have been done with doses up to 375mg/day for major depressive disorder. (This is for the instant release form - XR has different dosing.)

Thinking in terms of paroxetine (Paxil), that would be a large and inappropriate dose. Max dosing for paroxetine is in the 50-60 mg/day range.

The real problem is not the dosing, but the concerns about gradually increasing the dose. I would perhaps ask nicely to see the orders and MAR's to ensure that there was not actually a gradual increase (sometimes it's best to go to the source rather than someone's recollection.) The nursing manager might be a good source to work with to determine what happened.

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Specializes in Cardiac Telemetry, ED.

Is she still in the hospital? Why not try to meet with the doctor there?

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Specializes in Med Surg, Geriatrics, & Dialysis.

I do not think that you are overreacting. You have every right to question the doc about the med changes and you should have been notfied by your mother's nurse. This is your mom and you have every right to be an advocate for her. And I don't mean to sound like a b*t*h either but I worked in this type of facility for a number of years so I know what goes on in them, some of the time. Take care and I hope all goes well for your mother.

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Is she still in the hospital? Why not try to meet with the doctor there?

Re-read the post. She wants to but the doctor won't say when he rounds. He won't give her a time to meet there.

I'd look at the phone order and figure out what the order was supposed to be, who erred, get them corrected. Try to be nice, you've probably made mistakes, too. I know it's hard when it's someone you love. don't be wiesh washy, though, be firm that an error was made and your mom suffered harm. Of course, the doc could be lying to cover his bum.

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Specializes in Cardiac Telemetry, ED.
Re-read the post. She wants to but the doctor won't say when he rounds. He won't give her a time to meet there.

She said he wouldn't give her a time when he rounds at the care facility. Does this mean she is out of the hospital?

If the doctor won't meet with you, I'd maybe be thinking about getting a new one who will. Family members have got to be involved in the care plans of their elderly loved ones, so long as the elderly loved one wants the involvement, and the involved parties abide by the patient's wishes in their advocacy.

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A big thank you to everybody who took the time to respond. The story continued for a bit, but the situation is now being cleaned up.

The doc that prescribed the effexor was the "house" doc for the residential care facility where mom lives. While mom was in the hospital, the attending modified her dosage to 75mg as well as taking care of her other issues. Mom was sent from the hospital to a rehab center for short term rehab, the "house" doctor rounded on her there and increased the dosage immediately to 150mg.

I spoke on the phone at length with the doc. I told the doc that I was switching mom off the service and having Mom's PCP handle her needs. I explained nicely that I and my siblings were not comfortable with some of the decisions she had made regarding Mom's care without consulting us. Crack me up, it was as if I were speaking a foreign language. The 'thank you but, no thank you' that I tried to convey nicely was completely ignored. Doc started talking about well, I will prescribe this and lower the dosage on that, blah blah blah. I finally had to break it down, 'No, you don't need to do anything. She has a PCP, he can handle everything.'

So now Mom is doing as well as can be expected. She is on a reasonable dose of effexor and her PCP will allow her to stabilize on this dose and see if it is appropriate.

Again, thank you all for taking the time to respond. I do appreciate it.:redbeathe

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