My MIL has been put on pain meds for compound fractured vertabreas. Shes 86 and 77 pounds... The drs have added Fentanyl patch, lidocaine patch for pain, and nortriptline (pamelor) ... One of these is making her so confused. She is normally very sharp and aware of what is going on around her, but its almost like shes hallucinating at times... Does anybody have any idea which one of these 3 meds could be doing this to her? Thanks....
vicky

Hi Vicky

I hope mrsD will be online sometime today to help with this.

So sorry to hear of what your MIL is going thru.

The elderly do not clear meds easily and perhaps the doses are high for her
weight?

Is she taking anything else, say something for the stomach?
Like Tagamet or Pepcid? H2 antagonists can cause hallucinations in the
elderly (they are thought to cross the blood brain barrier in this group).
You might be focusing on the 3 newest drugs and ignoring the contribution
of a seemingly innocent drug-- and these are now over the counter...and can interact with other medications.

Nortriptyline can cause anticholinergic side effects in the elderly depending on dose. Many effects of anticholinergic actions can cause mental confusion or
frank delirium (belladonna alkaloids to do this too). It has to do with blocking
certain receptors in the brain. I would consider this possibility. Doctors give this drug for "nerve" pain. I would suggest the lowest dose to start, 10mg.
http://ajp.psychiatryonline.org/cgi/...ull/155/8/1110

Many people find fentanyl easier to tolerate for pain than other opiates. But if the dose is too high, then it can cause central nervous system effects too.

Here is her latest updated list of medications....
Prescription:

Fentanyl patch
Lidocaine patch
nortriptyline
asprin
iprat/albut inhaler
digoxin
diltiazem
pacerone
potassium chloride
furosemide
levothyroxine

Over the counter

Famotidine, (pepcid)
cocusate NA (colace)
Acetaminophen
mag-ag-sim (maalox)
Milk Of Magnesia susp


As you can see shes one sick lady. Shes got lymphatic leukemia, a lung infection that mimics TB, the broken vertabrae, and at one time they were saying she had chronic hepatitis. This confusion has just started since she started the pain meds for the broken vertabrae. They were taking about giving her a low does of neurontin, but its not on this list they gave us, so i dont know if they are or not.
Thank you so much MrsB. You are very knowledgable about this stuff and very helpful.... {{{HUGS}}}}
vicky

wow, mrsD that is VERY interesting
My MIL (87yo) was on Zantac and then Tagamet for a while, as well as some pretty strong pain med ........and we have been very concerned that she may have been showing signs of senile dementia

anyway, recently the doc took her off the H2 antagonists and put her on Prilosec( which is a proton pump inhibitor....right??).......and the strange behaviour and hallucinatory issues that she has been complaining of for some time now seem to have stopped!

Also, before we got the Crohn's dx for my son, one of the docs had him on tagamet, as they suspected he had an ulcer. Well, my son was having some very strange hallucinations just before falling asleep.......to the point that it was really worrying him and us. His OCD behavior also flared up.

Since getting the crohn's dx he no longer uses any tagamet and only occasional prevacid when in flare up...............and he hasnt had any hallucinatory probs for ages.....now, when I think about it....not since stopping the tagamet!

I'll have to remember this info- my dad takes meds for GERD and some pain meds for DDD and some meds for PD also.

If any odd behavior shows up I'll come back to this thread.

Vicky with that drug list.

1) Digoxin can become problematic when used with calcium channel blockers, and pacerone.
http://www.medicinenet.com/digoxin/article.htm
"mental changes" include delirium

2) the Combivent inhaler has an anticholinergic in it, and while most is not absorbed, it could be a bit additive with the nortriptyline. It is the Iprat portion.

3) furosemide seriously depletes Thiamine and magnesium. The potassium is well known, but the other two are critical in the elderly. Low Thiamine over time leads to a form of dementia...and also affects the nerves. So a thiamine supplement is a really good idea. Very low magnesium eventually impacts the heart, and rhythm. I would ask for a serum mag level. Esp with cancer. Chemo lowers mag significantly

4). Pacerone creates hypothyroidism, and a new test should be done.
The elderly can have sudden changes in thyroid function anyway, with trauma and stress. So hypothyroid effects would be "mental" as well.

Your MIL is on what we call a polypharmacy regimen. It is very hard to
control issues in someone so light in weight, and so old. I think at this time
the nortriptyline is really not that necessary.

You can also change the antacid drug to a proton pump inhibitor, and that might be better for her. Prilosec is OTC now, but it interferes with some drugs.
Prevacid would be a better choice, but some insurances won't pay for it now.

Vicky, you know me from SG--Belladonna
I am a pharmacist you know. So you can trust me.

Now that I have had dinner (after a long day at work )

I can post the documentation:

Full article:
http://www.medscape.com/viewarticle/408593_5

And this:
Many doctors do not realize that histamine is a neurotransmitter in the brain.
So H2 antagonists can affect that system. The BBB (blood brain barrier) is different from person to person. The Zonulin channels may let things pass more in one person than another. Zonulin is something hot now in research, and it is also involved in the "leaky gut" scenario, and the gluten folks here are pretty familiar with it. There is even a drug in phase III testing to block zonulin channels and hence prevent peptides for gaining access to where they don't belong. Zonulin channels are in both the GI tract and the blood brain barrier.

Complicated.... very!

I agree this is very complicated, but i do appreciate your input...
We are going to have a team meeting on Wednesday to discuss our concerns. supposedly the doctors, nurses and therapists will be there to tell us what they think and to answer our questions.... I'm going to use some of this information you've given us.
THANKS again!!!!!!!!!!
vicky

Is very common, and very disturbing. The anecdotal information published
on MedLine is often the only source now for many drug interactions. Death and disablility from misuse of prescription drugs is the 4 th leading cause of death in this country.
Articles like this are becoming more common every day:
http://friendsoffreedom.org/article....rder=0&thold=0

And sometimes people take so many drugs that the synergistic effects are
very hard to predict. Add in the unique metabolic functions in the elderly, and we have some very difficult situations that manifest.

Just managing thyroid functions can be very challenging for the geriatric
population. They can change rapidly.

Do keep us up to date on your MIL... I hope she finds the pain relief and quality of life she deserves.