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Management of BPSD Case.
Shahla Baharlou, MD and Christine Chang, MD
3-5-08
Part 1A: Robbin Green is a 78-year-old woman who comes to the office with her daughter, who
report that over the past 2 weeks, Robbin has been “acting up”. Daughter reports that she
repeats stories and packs her bags several times a day, stating that she is “going home.” She is
up frequently at night, pacing and wandering. The other day, she struck her home attendant.
History is significant for mild Alzheimer’s disease, hypertension, osteoarthritis, and urinary
incontinence. Her score on the Mini–Mental State Examination 6 months ago was 23 of 30. She
requires assistance in all instrumental activities of daily living (IADLs) but remain independent in
her basic activities of daily living. Her daughter prepours her medications which include
donepezil 5 mg daily, hydrochlorothiazide 25 mg daily, lisinopril 10 mg daily, baby aspirin,
oxybutynin 5 mg twice daily, and acetaminophen 500 mg once daily.
1. What do you do next?
a.
b.
c.
d.
e.
f.
Start haloperidol 0.5 mg at night
Start risperidone 1 mg at night
Increase donepezil to 10 mg
Increase oxybutynin to 10 mg twice a day
Increase acetaminophen to 1000 mg twice a day
Clarify the history and perform a careful physical and neurologic exam
Part 1B: Daughter reports that patient has been more incontinent these days but has had no
fevers, chills, flank pain or hematuria. Pt has been eating a little less as well but reports no
nausea, vomiting, diarrhea or constipation. ROS is otherwise negative. There are no new
medications and no changes in the care giving environment.
Physical exam showed a low grade fever 100.1, 110/70, 98, 12. Patient is oriented only to
person and does not know why she is in your office. She can answer simple questions but is
easily distracted. Exam is negative except for some suprapubic tenderness but no guarding,
rebound or CVA tenderness. Neuro exam is nonfocal though technically difficult.
You check a CBC differential, chemistries, UA and urine culture which reveal UA with positive
nitrites and leukocyte esterase, mild leukocytosis with left shift but otherwise normal chemistries.
You prescribe bactrim and Robbin’s incontinence and behavior returns back to baseline.
Part 2: Robbin is seen as an urgent visit 2 months later. Daughter reports that over the last 2
weeks that her mother has been getting more “agitated.” Daughter reports that the patient has
been screaming and scratching the new home attendant mainly during bathing. Daughter
normally tries to help the home attendant with her mother’s care but has been busier these days
as her grandchildren have been visiting. Daughter denies fever, chills, cough, shortness of
breath, pain, urinary or bowel symptoms. Robbin has been eating and sleeping as usual. Has no
new medications. Physical exam is unremarkable. Repeat MMSE remains 23/30.
2. What do you do next?
a.
b.
c.
d.
e.
f.
g.
Start haloperidol 0.5 mg at night
Start risperidone 1 mg at night
Increase donepezil to 10 mg
Start citalopram 10 mg daily
Start valproate 250 mg daily
Start carbamazepine 100 mg daily
Review nonpharmacologic, patient-centered interventions
Developed by Shahla Baharlou, MD and Christine Chang, MD 1-25-08
Part 3: Episodes of agitation during bathing resolve after the daughter and home attendant
implement a patient centered approach to bathing, adding lavender and patient preferred music
into the environment. Grandchildren have been better behaved during their visit. Over the next
year, Robbin returns with her daughter every three months for routine follow up of her chronic
conditions which are optimally controlled and monitored. On this particular visit, daughter reports
that for the past month she has had difficulty falling and staying asleep at night. Normally she
goes to bed at 9 pm and is able to sleep until morning. Now, she falls asleep around 10 pm and
sleeps until about 2 am, and awakens to go to the bathroom. She remains awake for several
hours, during which she is often disoriented, paces the house, and wakes her daughter. The
home attendant reports that since the weather has been “bad,” patient has not been able to go
out as she normally does. As a result, Robbin has been sitting around in a low lit living room and
“dozing” in front of the TV. Daughter reports that patient now needs reminders with some basic
ADLs but is independent with feeding, toileting, and ambulation. There is no evidence of sadness
or anhedonia, and she is eating well.
Physical exam and lab studies were within normal limits. GDS was negative.
3. What do you do next?
a.
b.
c.
d.
e.
f.
Prescribe zolpidem 5 mg
Recommend melatonin 0.3 mg
Prescribe triazolam 0.125 mg
Prescribe trazodone 25 mg
Prescribe mirtazapine 7.5 mg
Counsel about nonpharmacologic interventions to promote sleep
Part 4: Robbin returns one month later and daughter reports that your recommendations have
failed.
4. Which is the most appropriate pharmacologic treatment?
a.
b.
c.
d.
e.
f.
Prescribe diphenhydramine 25 mg
Prescribe zolpidem 5 mg
Prescribe melatonin 0.3 mg
Increase donepezil to 10 mg
Prescribe trazodone 25 mg
Prescribe mirtazapine 7.5 mg
Part 5: For the next 6 months, Robbin’s course is unremarkable as the donepezil 10 mg with the
intermittent trazodone 25mg has helped.
At her yearly physical, the daughter reports that Robbin has become increasingly quiet and
withdrawn over the last 2 months. She is no longer interested in going outdoors or watching some
of her favorite TV shows. She is eating poorly and has lost 4.5 kg (10 lb). Over the last 2 weeks,
daughter has notice that the patient has been napping more in the daytime and then remains
awake all night wandering and pacing around the house. Pt reports no suicidal ideation.
On exam, patient affect appears flatten. GDS=6/15 (abnl >5). Physical exam is otherwise
unremarkable. Lab work up including chemistries, cbc and tsh are negative.
Developed by Shahla Baharlou, MD and Christine Chang, MD 1-25-08
5. What is the most effective initial management strategy for this patient?
a.
b.
c.
d.
e.
Enrollment in Adult Day Health Care Center
Caregiver education and training in coping skills
Prescribe nortriptyline 25 mg
Prescribe sertraline 25 mg
ECT (Electroconvulsive Therapy)
Part 6: Robbin returns 2 weeks later and reports that the initial treatment was unhelpful.
6. What would you do next?
a.
b.
c.
d.
Switch to another agent in same class
Switch to another agent in another class
Titrate dose of initial medication
Add methylphenidate 5 mg daily
Part 7: Robbin responds well to sertraline 50 mg which you continue for the next 12 months.
Over the next 2 years, daughter reports that Robbin gradually requires more assistance with all of
her ADLs despite addition of memantine 10 mg twice a day. Initially she required just prompting,
but now need more hands on care from the home attendant for feeding, dressing, toileting,
ambulating and bathing. She appears confused more often and at times does not recognize her
daughter. For the last month, patient has not been able to sleep at night because of “intruders”
trying to break into her room at night.
Again there are no new medications, no change in the caregiving environment. Her physical
exam and laboratory workup are negative.
7. What is your recommendation?
a.
b.
c.
d.
e.
Refer for nursing home placement
Do a time-limited trial of haloperidol 0.5 mg
Do a time-limited trial of risperidone 0.5 mg
Do a time-limited trial of olanzapine 5 mg
Do a time-limited trial of valproate 250 mg
Robbin does not respond to the risperidone 0.5 mg so you titrate it to 1mg and it appears to work.
You continue this for 4 weeks and eventually you are able to wean it off.
Developed by Shahla Baharlou, MD and Christine Chang, MD 1-25-08