Getting psychiatric help for Dad in assisted living?
So, here's the cast of characters...
1. My brother and I, both out of state
2. Dad, in Massachusetts, 91, in assisted living, with Parkinson's, moderate cognitive issues, and depression. Already on some meds, and on Medicare (not Medicaid)
3. Stepmom, 88, living at home in Mass., with cancer (although doing better overall than Dad)
4. NP, the Nurse Practitioner who's seen my dad several times already
5. GP, Dad's doctor, who sees him all of about 15min four times a year. Somewhat contentious relationship between him and Dad.
6. Exec, the executive director of the Assisted Living facility.
So, Dad's been in AL for almost two months. NP visited him about a month ago (has seen him 3x, I think), and seemed to develop a good rapport. Initially, she mentioned having a psychiatrist colleague to come in and work with Dad and also test his cognitive capabilities.
She has since mentioned some suggested changes to his meds to reduce his depression and his anxiety (notably because his wife his not living with him). However, she has noted that, because she's an NP, she can only suggest medication changes.
NP did bring in a psychiatrist, who ran some tests. I have a copy of those results. He also suggested that Dad's health care proxy be invoked (putting me in charge). Those results have also been sent to the GP.
GP appears comfortable letting a psychiatrist make changes to the meds; I have not spoken to GP firsthand, but we have a woman who's been helping out there with both Dad and stepmom who has spoken to him.
Exec told us a 'registered therapist' saw Dad (and stepmom) this past week, and will continue to see Dad regularly. However, not clear she's an actual psychiatrist.
My brother and I think what Dad needs is regular psychiatric help and some changes to his meds, but aren't sure how to make that happen.
I plan to call GP regarding the psychiatrist's recommendation about the health care proxy, but am not sure what else to do to make all this happen.
Suggestions?
14 Answers
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I work with a psychiatric nurse practitioner who does the meds and I do the therapy or behavioral planning on dementia unit. We are both there one day per week - sometimes two. Usually when the NP sees someone & she has a recommendation the staff fax her note to the doctor and keep any responses to share with her when she comes back the next week. She really goes above and beyond what most psych prescribers do - she will speak to the PCP office if needed. Then the PCP writes the order which then gets faxed to the pharmacy but my NP now has a prescription pad for any doctor that does not want to touch the psych meds at all. This is a new development for our team so I am not sure any other psych consultants are doing this but it doesn't hurt to ask. Funny the primary care NP told you they can't write Rx's - I thought that is what differentiated them from RNs? Perhaps she meant discomfort with psych meds?
Either way - I have found that thought even they are able to do so - more and more doctors in primary care do not want to touch the psych meds - esp for dementia/alzheimer's. Understandable - managing psych meds are a delicate process which needs a slow and careful approach fully integrated with the therapist seeing your dad. When I am working with someone - it's my visits that give vital info on whether the meds are working according to staff and my observations.
If your dad is early in the process and you want more info on his baseline memory/cognitve functioning - I would suggest you see a neuropsychologist for further testing & diagnosis. It's a rare but often the better neurologists that will prescribe the meds your PCP isn't comfortable with - but in my experience neurologist are better suited to manage movement disorders like parkinsons but not mental health.
Bottom line is the psychiatrist should be the one managing his meds (not just doing testing) along with the therapist working in concert to meet the goals you set as his HCP. In facilities where they do medication assistance - staff will help the process along but it is slow and they have many people to care for.
If you want some more help with this - I would ask the woman (certified care manager I hope!) you have hired if she provides this type of clinical case management. If you can afford to have her do it and she is qualified - then she becomes the point person to make sure everyone is on the same page (psychiatrist, therapist, GP, faculty staff, you and any other caregivers involved). Saves a lot of time and hassle for you and since she would know the system better - the hope is that outcomes will be better having her in charge.
Hope that helps!
1. "Funny the primary care NP told you they can't write Rx's" The PCP seems to support this notion, referring to her as a 'consultant'. Dad's neurologist's assistant, however, was surprised at this as well--perhaps it's a restriction from Medoptions, her employer.
2. "If your dad is early in the process and you want more info on his baseline memory/cognitve functioning - I would suggest you see a neuropsychologist for further testing & diagnosis." A psychologist (not a psychiatrist) from Medoptions did a full workup which was faxed to the PCP and neurologist (and I have a copy as well).