"You're talking about a set of patients who are on the razor's edge of risk," he said.
Risperdal didn't fix everything, but gradually, Kathye grew calmer. After several months on the drugs, she developed Parkinsonian symptoms - twitching, difficulty walking that caused her to fall - that are a well-known side effect of antipsychotic drugs.
Karlawish began reducing the Risperdal slowly, using feedback from Bill to prevent behavioral flare-ups. Today, Kathye is off the medicine. She is calm, but some of the Parkinson's symptoms remain.
"I knew it was a dirty drug," Bill Wiggins said, "but I was concerned about her safety and less concerned with the side effects."
Bill Wiggins has found a new caregiver, Christine Quoikapor, who, he said, "has been a godsend." He leaves the house now with far less worry.
"It's an imperfect world," Bill Wiggins said. "You could really drive yourself crazy trying to second-guess yourself. And I've done a lot of that, frankly. I know she would not want to be as she is. There are days that I ask myself - am I extending something that she doesn't want by the way I've been taking care of her? It's one of those things where you do whatever you think is right and hopefully it is. But at the end of the day, you won't know."
Helen Marciniszyn was the kind of mother and grandmother who baked cookies, counted them out, and put an equal number in a tin labeled with each granddaughter's name.
"She stayed home and took care of the family," said her daughter Helen Shields, who lives in Middletown, Del.
When her mother began having trouble taking care of herself in 2000, Helen Shields quit her job as a doctor's receptionist to care for her. For eight years, Shields drove an hour each way to and from her mother's Chester home.
In 2006, when her mother was 89, her memory had dimmed so much that she recognized almost no one except her daughter. Marciniszyn was eating poorly, and her daughter and son decided she would be better off in a nursing facility.
They chose New Seasons at Glen Mills, an assisted-living facility that promised good medical care and stimulating activities.
On Feb. 10, 2006, one day after New Seasons admitted Marciniszyn, Richard Dimonte Jr., a Media doctor, prescribed Seroquel for her. She was a new patient to Dimonte, who never examined her and prescribed the drug over the phone, according to a 2007 lawsuit that Shields filed against New Seasons and Dimonte.
Documents from New Seasons do not list a reason for the Seroquel prescription, Shields' lawyers, Robert L. Sachs Jr. and Chad Galvin, said. Dimonte, through his lawyer, declined to comment because the matter is in litigation.
On Feb. 20, 2006, Dimonte added Ativan, an anti-anxiety drug, to Marciniszyn's prescriptions, court documents say. Seroquel, along with other antipsychotics, and Ativan sedate users, creating a risk of falling, especially in the elderly.
Five days later, Marciniszyn was found on the floor of her room at New Seasons.
When an ambulance arrived, emergency workers found her sitting in a wheelchair in the nursing office.
They transported her to Riddle Memorial Hospital, where an X-ray showed a fracture in her right femur. She had surgery to fix her right hip on March 9, 2006 and died April 8 as a result of injuries from the fall. The hospital is not a defendant in the suit.
Independence Blue Cross, which owned New Seasons at Glen Mills when Marciniszyn was there but has sold it, said it would defend itself against the suit but would not comment further because federal regulations forbid discussing patients.
Shields says no one told her when Dimonte prescribed Seroquel and Ativan to her mother. In her suit, Shields also alleges that New Seasons did not hire and properly train enough staff to care for her mother and other patients.
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