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Nonpharmacologic Management of BPSD Cases
Christine Chang. MD
CASE 1:
PART 1: You are seeing Mrs. Robbin Green, a 78-year-old with mild Alzheimer’s
disease (MMSE 23 of 30), hypertension, osteoarthritis, and urinary incontinence who
comes to the office with her daughter for “acting up” for past 2 weeks. 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.
Medications: donepezil 5 mg daily, hydrochlorothiazide 25 mg daily, lisinopril 10 mg
daily, baby aspirin, tolterodine LA 2 mg, and acetaminophen 500 mg once daily.
1. How would you approach this case?
PART 1 continued: 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 is unremarkable except for Temp 100.1, mild suprapubic tenderness
without guarding or rebound or CVA tenderness. Neurological exam is nonfocal though
technically difficult. She is oriented only to person and easily distracted.
Labs are unremarkable except for urine with positive nitrites and leukocyte esterase, and
CBC with mild leukocytosis with left shift.
2. What is the most appropriate treatment?
PART 2: Mrs. Green is seen as an urgent visit 2 months later for being 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. She has been eating and sleeping as usual. No other symptoms reported nor
are there any new medications. Physical exam is unremarkable. Repeat MMSE remains
23/30
3. What is the most appropriate approach?
November 1, 2015
Nonpharmacologic Management of BPSD Cases
Christine Chang. MD
CASE 2: Robert Kahn is an 85 year old retired salesman with history significant for
CAD, HTN, prostate cancer (treated, in remission), and moderate Alzheimer’s dementia.
Patient lives alone in an apartment one level below his son’s. He is independent in his
ADLs. He is brought in for urgent visits by his son with complaints of inability to sleep
at night for past month. He was noted to be taking naps in his lazy chair during the day.
He has gained 5 pounds since his last visit 3 months ago. He denies being depressed. He
does confirm trouble falling sleep but is unable to provide a more comprehensive history.
4. What is your first intervention?
a.
b.
c.
d.
e.
f.
Prescribe zolpidem 5 mg
Recommend melatonin 1.5 mg
Prescribe triazolam 0.125 mg
Prescribe trazodone 25 mg
Prescribe mirtazapine 7.5 mg
Counsel about non-pharmacologic interventions to promote sleep
5. What is your next approach if your first intervention fails?
a. Prescribe diphenhydramine 25 mg
b. Prescribe zolpidem 5 mg
c. Prescribe melatonin 1.5 mg
d. Increase donepezil to 10 mg
e. Prescribe trazodone 25 mg
f. Prescribe mirtazapine 7.5 mg
CASE 3: Julia Gross is a 90 year old, a retired special education teacher with Masters
degree in education and Psychology who is seeing you for follow up. She has a history of
HTN, Mild Alzheimer, gait impairment and falls. During today’s visit she reports feeling
depressed about her loss of function and memory. She reports decrease appetite and has
lost 6 pounds in past four months. Mrs. Gross reports feeling fatigued and difficulty
falling and staying asleep. Her daughter is very concerned about patient’s decline.
Medications include: donepezil 10mg daily, amlodipine 5 mg daily. Physical exam and
Labs are unremarkable. Her MMSE is 24 which is unchanged from six months ago.
6. What are the differential diagnoses?
7. How would you treat this patient?
a. Enrollment in Adult Day Health Care Center
b. Caregiver education and training in coping skills
c. Prescribe nortriptyline 25 mg
d. Prescribe sertraline 25 mg
e. ECT (Electroconvulsive Therapy)
November 1, 2015
Nonpharmacologic Management of BPSD Cases
Christine Chang. MD
CASE 4: David Smith is a 77 year old retired businessman, with history of Alzheimer’s
disease diagnosed 7 yrs ago. He is an Ex alcoholic, has been sober for over 20 years. He
has been progressively more dependent in ADLS in past 1 year, and has developed
urinary incontinence over past six months. His wife has hired Mary to help with David’s
care six months ago. Today Mrs. Smith reports that he has been more and more resistant
to personal care including bathing, shower and toileting over past two months. In few
instances he became physically aggressive toward his wife and his aide Mary. Mrs.
Smith and Mary have employed appropriate non-pharmacologic interventions without
much success. Delirium has been ruled out. His medications include donepezil 5 mg
daily and senna PRN.
8. When would you consider any medications?
9. What medication would you consider in treating his symptoms?
a.
b.
c.
d.
e.
f.
g.
h.
Increase donepezil to 10 mg daily
Start memantine 5 mg daily
Time-limited trial of risperidone 0.5 mg
Time-limited trial of haloperidol 0.5 mg
Time-limited trial of olanzapine 5 mg
Time-limited trial of valproate 250 mg
Time limited trial of sertraline 50 mg daily
Start a trial of prazosin1mg daily
November 1, 2015