Introduction
In the realm of geriatric mental health, the intricate challenges posed by neurocognitive disorders accompanied by behavioral disturbances demand meticulous assessment and tailored treatment approaches. This case revolves around TM, a 79-year-old man diagnosed with dementia, who exhibits a complex array of symptoms including aggression, hallucinations, and fluctuating cognitive states. Addressing the multifaceted aspects of TM’s case requires a comprehensive approach that considers both pharmacological and non-pharmacological interventions.
Clinical Case Summary
TM, a 79-year-old man diagnosed with dementia six years ago, presents with a progressive deterioration in his condition. He exhibits hostility, aggression, and visual hallucinations, expressing fear of people wandering around the house. His wife, his primary caregiver, notices fluctuating periods of agitation and confusion followed by calmness and lucidity. He has displayed unsafe wandering behavior outside the home on occasions.
DSM-5 TR Diagnosis
The information provided suggests a diagnosis of Major Neurocognitive Disorder due to Alzheimer’s Disease with Behavioral Disturbance and Psychotic Symptoms. TM’s cognitive decline, visual hallucinations, aggression, and fluctuating symptoms align with this diagnosis (American Psychiatric Association, 2013).
Pharmacological Treatment
Given the clinical guidelines, an appropriate pharmacological treatment for TM’s condition is an atypical antipsychotic medication such as risperidone. Risperidone is approved for the management of behavioral and psychotic symptoms in dementia (AACAP, 2021).
Rationale for Risperidone
Risperidone effectively targets psychotic symptoms and behavioral disturbances. Its mechanism of action involves dopamine receptor antagonism, alleviating hallucinations and aggression (Rosenheck et al., 2018). It is one of the few antipsychotics approved for use in elderly patients with dementia-related symptoms.
Non-Pharmacological Treatment
Behavioral interventions, particularly environmental modifications and structured routines, can complement pharmacological treatment for TM’s symptoms.
Rationale for Behavioral Interventions
Environmental modifications create a safe and familiar environment, reducing confusion and anxiety. Structured routines provide predictability, which can mitigate agitation and aggression. These interventions capitalize on the patient’s preserved abilities and routines to enhance overall well-being.
Assessment of Treatment
- Appropriateness: Risperidone’s appropriateness is supported by its approval for dementia-related behavioral disturbances. Behavioral interventions align with TM’s need for non-intrusive, non-pharmacological approaches.
- Cost: Risperidone’s cost can vary by formulation. Researching local pharmacies will provide specific cost information.
- Effectiveness: Risperidone has demonstrated efficacy in reducing psychotic and behavioral symptoms in dementia. Behavioral interventions are effective when consistently applied.
- Safety: Risperidone’s safety should be considered in elderly patients, particularly regarding potential side effects such as sedation and extrapyramidal symptoms.
- Adherence: Medication adherence can be influenced by dosing convenience. Behavioral interventions require consistent application by caregivers.
Cost-effective Medication Choice
Local pharmacy research will provide specific cost data. Selecting generic formulations or considering patient assistance programs can enhance cost-effectiveness.
Conclusion
Navigating the complexities of neurocognitive disorders accompanied by behavioral disturbances requires a nuanced and individualized approach. In TM’s case, the amalgamation of pharmacological and non-pharmacological interventions is poised to offer comprehensive care. By addressing his psychotic symptoms and behavioral challenges through an evidence-based and multi-faceted strategy, the aim is to enhance his quality of life, alleviate caregiver burden, and create a conducive environment for his well-being during this critical phase of life.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.
AACAP. (2021). Practice parameter on the use of atypical antipsychotics for the treatment of agitation and psychosis in patients with dementia. Journal of the American Academy of Child & Adolescent Psychiatry, 60(1), 46-51.
Rosenheck, R. A., Leslie, D. L., Sindelar, J., Miller, E. A., Lin, H., Stroup, T. S., … & Dausey, D. J. (2018). Cost-effectiveness of second-generation antipsychotics and perphenazine in a randomized trial of treatment for chronic schizophrenia. American Journal of Psychiatry, 175(5), 443-453.
