![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 12 of 12. This is the beginning of the thread.
Posted by gregm2 on April 14, 2002, at 9:07:40
My father is 75 years old and had a depression crisis 3 years ago. He was hospitalized and his condition was diagnosed (?) as organic psycho- syndrome. He has tried several medications (anti-depressants, neuroleptics) and suffered with a lot of side effects (e.g. anorexia, parkinsonism due to the neuroleptics, etc).
For the past year or so, he is taking the following medication:
Remeron (mirtazapine): 45 mg daily (15mg morning, 30 mg evening
Stedon (diazepam): 7.5 mg daily (2.5 mg morning, 5mg evening)
Memodrin (aniracetam): 1500mg daily (750mg morning, 750mg afternoon)
Atarax(hydroxyzine): 150 mg daily (50mg, 3 times daily)He has followed the above scheme for more than a year now, and has been relatively OK moodwise. During this time, he almost never went out of home (one reason is that his legs are not very strong).
For the past 2 weeks he is feeling anxiety and the doctor has increased the diazepam dose by 5mg (up to 12.5). The result is that the anxiety has only decreased a little, but he seems like he is "lost" and confused (he does not talk a lot, he "stares" on the wall, he does not answer if we ask him a question).
I am worrying that taking benzodiazepines (diazepam) for such a long time may be harmful, and also in combination with all these drugs. We have been to a lot of psychiatrists and the current doctor who follows his case is a neurologist. Please help with any suggestions!
Posted by katekite on April 14, 2002, at 14:41:28
In reply to remeron and diazepam, posted by gregm2 on April 14, 2002, at 9:07:40
Hi,
Your father sounds pretty complicated. I guess I would have to recommend not paying too much attention to long distance opinions. It sounds like a neurologist is the right place to be, perhaps you could get one or two more neurologists as second and third opinions. Lastly if you have any specialty psychopharmacologists in the area that would be another specialist to consider seeing. Entering psych world is like going to a foreign country: always ask directions from three different people.
Another thing to do might be to ask for a new set of testing: there are good (and expensive, probably) cognitive function, memory and 'personality' (more like variety of depression test) tests, screening for anything that may have subtly changed over the last year.
Also, since he's been on this combination for so long and just now experiencing more anxiety, is there any chance he has started to eat anything different with his pills, changed the timing, or anything different that could affect absorbtion or metabolism? For example a stomach bug a few weeks back, anything like that? There's always the chance of a separate medical condition coming into play, make sure he's had a recent physical, that his blood pressure is the same as always, etc.
Good luck. Hope he feels better soon.
kate
Posted by gregm2 on April 15, 2002, at 2:34:21
In reply to Re: remeron and diazepam, posted by katekite on April 14, 2002, at 14:41:28
Thank you very much for your response Kate,
The new thing is that yesterday the doctor (neurologist) suggested to
start xanax 0.25 mg two times per day (morning and afternoon) and keep
the diazepam (7.5mg) once per day (every evening).
My father is quite nervous (is standing up almost all the time)
and wakes up much earlier than usual in the morning.
The strange thing is that he looks quite confused
and does not answer any questions (he seems like he is not
paying attention).
His blood pressure has slighlty increased (140-150/ 80)
and he is taking 25 mg of moduretic (I think it is ...amiloride?)
every morning.Any suggestions are more than welcome.
Thank you again.
Posted by fachad on April 15, 2002, at 19:19:11
In reply to remeron and diazepam, posted by gregm2 on April 14, 2002, at 9:07:40
That's a powerful cocktail with whopping doses for a geriatric patient.
There are specific warnings about giving hydroxyzine to old folks, because it lasts a long time in the body, has anti-cholinergic effects, and causes confusion and falls.
Also, diazepam in the elderly is usually not a good idea because it lasts a long time in the body and builds up over time, again causing confusion and falls.
Usually, docs like to give geriatric patients short acting benzos - Ativan, Serax, and Xanax are favorites, because they pass out of the body quickly and do not have any active metabolites.
Does the Remeron make him eat a lot and sleep all the time?
> My father is 75 years old and had a depression crisis 3 years ago. He was hospitalized and his condition was diagnosed (?) as organic psycho- syndrome. He has tried several medications (anti-depressants, neuroleptics) and suffered with a lot of side effects (e.g. anorexia, parkinsonism due to the neuroleptics, etc).
> For the past year or so, he is taking the following medication:
> Remeron (mirtazapine): 45 mg daily (15mg morning, 30 mg evening
> Stedon (diazepam): 7.5 mg daily (2.5 mg morning, 5mg evening)
> Memodrin (aniracetam): 1500mg daily (750mg morning, 750mg afternoon)
> Atarax(hydroxyzine): 150 mg daily (50mg, 3 times daily)
>
> He has followed the above scheme for more than a year now, and has been relatively OK moodwise. During this time, he almost never went out of home (one reason is that his legs are not very strong).
> For the past 2 weeks he is feeling anxiety and the doctor has increased the diazepam dose by 5mg (up to 12.5). The result is that the anxiety has only decreased a little, but he seems like he is "lost" and confused (he does not talk a lot, he "stares" on the wall, he does not answer if we ask him a question).
> I am worrying that taking benzodiazepines (diazepam) for such a long time may be harmful, and also in combination with all these drugs. We have been to a lot of psychiatrists and the current doctor who follows his case is a neurologist. Please help with any suggestions!
Posted by gregm2 on April 16, 2002, at 13:52:03
In reply to Re: remeron and diazepam » gregm2, posted by fachad on April 15, 2002, at 19:19:11
Thank you for your interest and your suggestions fachad,
The problem with my fathers case is that he did not get the proper attention by doctors, maybe because he is 75 years old. What I haven't mentioned is that I am posting from Greece... I am under the impression that neurologists in Greece are maybe not so experienced and (I dare to say)concerned about cases like my fathers.
This is the reason why I have started to read a lot about the neurochemistry of such diseases and the related pharmacology. In some cases I informed doctors about the side-effects of some medicines (!!), which I think is not the right way of information flow(!)
It is the first time that I post messages on a board and I must say I am very pleasantly surprised by the response and concern I get.Regarding short acting benzos, the doctor has replaced two out of the three doses of diazepam with 2 x 0.25 mg Xanax, and kept a dose of diazepam (7.5mg) for the evening. It is the second day that he has done that change and he is slightly less anxious but still seems quite confulsed. His muscle strength has decreased quite a lot but he "likes" to stand up almost all day! (probably because he is feeling nervous).
Regarding Remeron, the 15mg in the morning and the 30mg in the evening were working perfectly until the point he had this "anxiety attack" (10 days ago). His appetite was increased quite a lot and his night sleep was lasting about 9 hours.
After the "anxiety attack" he has lost his appetite and he was waking up in the middle of the night and early in the morning. This is why the doctor increased diazepam from 7.5 mg per day to 12.5mg per day. Maybe this change has caused more trouble...I don't know.
You have mentioned about the anticholinergic effects of hydroxyzine. Can you please give me some examples of anticholinergic effects? My father takes Hydroxyzine hydrochloride (a medicine called Atarax in Greece). He is taking 50mg of this 3 times per day (total 150mg). I am under the impression that it does not do anything for him because the doctor has doubled this dose when the "anxiety attack" started, but we saw no effect and went back to the 3 x 50 mg. Do you think that this is something he should not take? I am just asking for an opinion.
I am sorry for the long reply but my family and I are going thorough a very rough time and any help is much appreciated.
Thank you once more.
Posted by fachad on April 16, 2002, at 16:04:51
In reply to Re: remeron and diazepam, posted by gregm2 on April 16, 2002, at 13:52:03
> You have mentioned about the anticholinergic effects of hydroxyzine. Can you please give me some examples of anticholinergic effects?
Anticholinergic effects are dry mouth, blurred vision, constipation, urinary problems, heart rhythm problems, and mental confusion. They are a real nuisance in young people, but they can be medically serious in old people.
Atarax is an old anxiety med, not used very much any more in the US because it causes too much sleepiness and anticholinergic effects, and does not really help anxiety that much.
What happened with his "anxiety attack"? Are they sure it was not some other medical problem that caused the anxiety?
Using psych meds in the elderly is very difficult because their bodies do not eliminate meds very well, and they are prone to confusion and dementia anyway.
> Thank you for your interest and your suggestions fachad,
>
> The problem with my fathers case is that he did not get the proper attention by doctors, maybe because he is 75 years old. What I haven't mentioned is that I am posting from Greece... I am under the impression that neurologists in Greece are maybe not so experienced and (I dare to say)concerned about cases like my fathers.
> This is the reason why I have started to read a lot about the neurochemistry of such diseases and the related pharmacology. In some cases I informed doctors about the side-effects of some medicines (!!), which I think is not the right way of information flow(!)
> It is the first time that I post messages on a board and I must say I am very pleasantly surprised by the response and concern I get.
>
> Regarding short acting benzos, the doctor has replaced two out of the three doses of diazepam with 2 x 0.25 mg Xanax, and kept a dose of diazepam (7.5mg) for the evening. It is the second day that he has done that change and he is slightly less anxious but still seems quite confulsed. His muscle strength has decreased quite a lot but he "likes" to stand up almost all day! (probably because he is feeling nervous).
>
> Regarding Remeron, the 15mg in the morning and the 30mg in the evening were working perfectly until the point he had this "anxiety attack" (10 days ago). His appetite was increased quite a lot and his night sleep was lasting about 9 hours.
> After the "anxiety attack" he has lost his appetite and he was waking up in the middle of the night and early in the morning. This is why the doctor increased diazepam from 7.5 mg per day to 12.5mg per day. Maybe this change has caused more trouble...I don't know.
> You have mentioned about the anticholinergic effects of hydroxyzine. Can you please give me some examples of anticholinergic effects? My father takes Hydroxyzine hydrochloride (a medicine called Atarax in Greece). He is taking 50mg of this 3 times per day (total 150mg). I am under the impression that it does not do anything for him because the doctor has doubled this dose when the "anxiety attack" started, but we saw no effect and went back to the 3 x 50 mg. Do you think that this is something he should not take? I am just asking for an opinion.
> I am sorry for the long reply but my family and I are going thorough a very rough time and any help is much appreciated.
> Thank you once more.
Posted by gregm2 on April 17, 2002, at 13:04:07
In reply to Re: remeron and diazepam » gregm2, posted by fachad on April 16, 2002, at 16:04:51
The news with the "anxiety attack" are as follows:
Yesterday evening my father was feeling very anxious (he was standing up all the time and we could not make him sit down very easily). At night, he woke up at 4:00 after taking 7.5 mg diazepam before bed. It was impossible to make him lie down. I have given him an additional 2.5 mg diazepam and did not work for 1.5 hours and then I gave him 0.25 xanax with only little effects! It was a terrible night.Today the doctor has changed his medication as follows:
He added 20mg of temazepam (trade mark Normison) before bed.
He increased xanax to 0.375mg x 3 times per day
He stopped completely the diazepam (which my father was taking for almost 2 years!)
The Atarax is continued (150 mg daily)
Remeron is continued (45mg daily)
Memodrin (aniracetam) is continuedI am waiting to see the results tonight....
I am really scared with these changes
What do you think?
Posted by fachad on April 19, 2002, at 13:31:11
In reply to Re: remeron and diazepam, posted by gregm2 on April 17, 2002, at 13:04:07
I don't want to alarm you and that is why I did not ask this earlier, but has your father's doctor considered that he may have had a mild stroke or age related dementia or beginning Alzheimer’s?
I took care of my father until he passed away in April 2000, and he had lifelong anxiety, but after he had a light stroke, his behavior would sometimes become bizarre.
My mother is now in a nursing home, and she is fine some days and other days she is really confused and restless. Her doctor says its age related dementia. Just as physical health deteriorates with age, so does mental health.
Regarding his current meds, I personally think temazepam is worthless, but some people swear by it. Do you have Ambien (zolpedem) or Sonata (zaleplon) where you are? They are really good sleep meds for the elderly becasue they work rapidly and they are eliminated rapidly so they do not contribute to confusion on the next day.
Remeron blocks histamine so powerfully I doubt if there is a single receptor left in his entire body for the hydroxyzine to attach to. But the combo of Remeron and hydroxyzine would make me sleep for days, eat everything in sight, and be mentally confused.
We don't have Memodrin (aniracetam) in the US, so I don't know what to expect from that.
I would just ask his doc if stroke or Alzheimer’s has been ruled out.
> The news with the "anxiety attack" are as follows:
> Yesterday evening my father was feeling very anxious (he was standing up all the time and we could not make him sit down very easily). At night, he woke up at 4:00 after taking 7.5 mg diazepam before bed. It was impossible to make him lie down. I have given him an additional 2.5 mg diazepam and did not work for 1.5 hours and then I gave him 0.25 xanax with only little effects! It was a terrible night.
>
> Today the doctor has changed his medication as follows:
>
> He added 20mg of temazepam (trade mark Normison) before bed.
> He increased xanax to 0.375mg x 3 times per day
> He stopped completely the diazepam (which my father was taking for almost 2 years!)
> The Atarax is continued (150 mg daily)
> Remeron is continued (45mg daily)
> Memodrin (aniracetam) is continued
>
> I am waiting to see the results tonight....
> I am really scared with these changes
> What do you think?
Posted by gregm2 on April 21, 2002, at 14:43:21
In reply to Have Stroke or Dementia been Ruled Out? » gregm2, posted by fachad on April 19, 2002, at 13:31:11
Dear fachad,
I am really grateful that I receive your response in a time that I am so much confused. In the country that I live (Greece) there is not so much help and support. I am sorry about your father and I hope it goes "well" with your mother. It is terrible to see your folks like that! For the last 3 years I have been trying to deal with my fathers problem, and it is really tough.
To the point now: Before the recent anxiety attack, we went to the doctor and he examined my father. His memory and reactions as well as his understanding was very good. He was watching the news and he was aware of everything that was going on in the world! He was playing with his grandchildren and was smiling (very rare for him in the last 3 years). So Alzheimer's can be (sort of) ruled out. As far as the mild stroke is concerned, he has had CT scans and MRI of his brain and some "dead" regions were visible. The doctors said that these could be one reason for the start of his condition. However, people at his age (75) usually have such brain "lesions".I personally think that "something" happened that made him anxious (maybe a change in his brain chemistry) and then the doctor changed the medications and....we are still trying to find the right combination.
The news about his condition are:
He has been quite anxious in the recent days (especially in the morning) after the doctor changed his medications (see my posting on 4/16).
He looks like he has lost his muscle tone (he is slightly bent forwards) but he still wants to stand up almost all the time. He is sweating a lot when he is standing up and the "tone" of his facial muscles seems to have decreased. I have considered the possibility of a "deprivation syndrome" due to the shift from diazepam to xanax and temazepam.
Todays change of medications by the doctor is a decrease of xanax from 3 x 0.375 per day to 3 x 0.25 per day.
What do you think?
Posted by gregm2 on April 23, 2002, at 8:30:42
In reply to Re: Have Stroke or Dementia been Ruled Out?, posted by gregm2 on April 21, 2002, at 14:43:21
after a week on xanax (3 x 0.25 mg), my father looks like he has lost a lot of his intellectual abilities and is quite confused. Before starting xanax he has been taking diazepam (about 7.5 mg per day) for almost 1.5 years.
THe doctor has suggested to go back to diazepam. What do you think about these changes
Posted by fachad on April 23, 2002, at 15:10:31
In reply to urgent_ deprivation syndrome?, posted by gregm2 on April 23, 2002, at 8:30:42
> after a week on xanax (3 x 0.25 mg), my father looks like he has lost a lot of his intellectual abilities and is quite confused.
My mother lost most of her intellectual abilities and we thought she had lost her mind after only a few doses of Ativan (lorazepam). When we quit the lorazepam, she got back to normal in a few days.
Before my father passed away his doc tried to switch him from Librium (chlorodiazepoxide), which he had been taking for 30+ years to Xanax. He hated the Xanax, it made him moody and irritable, and we begged his doc to switch back to Librium.
What the doctors are thinking is that the quick acting drugs like Xanax or Ativan do not build up in old people's systems, but I think the fact that those two are "high potency" benzos makes them hit old folks harder.
Maybe you could have your dad try Serax (oxazepam). It is a "low potency" benzo with a very short half-life and no active metabolites.
> after a week on xanax (3 x 0.25 mg), my father looks like he has lost a lot of his intellectual abilities and is quite confused. Before starting xanax he has been taking diazepam (about 7.5 mg per day) for almost 1.5 years.
> THe doctor has suggested to go back to diazepam. What do you think about these changes
Posted by gregm2 on April 24, 2002, at 9:39:27
In reply to Re: urgent_ deprivation syndrome? » gregm2, posted by fachad on April 23, 2002, at 15:10:31
This is the new "recipe" by the doctor, starting today:
back to diazepam (10mg per day in 3 doses)
remeron goes up to 60mg (!) 15mg morning, 15mg afternoon, 30mg evening
temazepam 20mg before bedtime
I will let you know about the results
the "funny" thing is that when we stopped xanax and gave diazepam instead (yesterday), my father started looking much better than the terrible state he was at (trembling jaw, absolutely no talking and no response when you ask him something)Thanks again
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.