Dementia Treatment

TM is a 79-year-old man who was diagnosed with dementia 6 years previously. He lives with his 72-year-old wife. He was a chain smoker for 45 years.  She describes a gradual deterioration in his condition such that in recent months she has found it increasingly difficult to manage him. He has become increasingly hostile and aggressive, though he has not actually assaulted her. He has begun to complain about seeing people wandering around the house, and that frightens him. On two occasions he has left the house and been found wandering along the road. She has noticed that his condition fluctuates – sometimes he is very aggressive and confused, while at other times he is more calm and lucid.

1. Summarize the clinical case.
2. What is the DSM 5-TR diagnosis based on the information provided in the case?
3. Which pharmacological treatment would you prescribe according to the clinical guidelines? Include the rationale for this treatment.
4. Which non-pharmacological treatment would you prescribe according to the clinical guidelines? Include the rationale for this treatment excluding a psychotherapeutic modality.
5. Include an assessment of the treatment’s appropriateness, cost, effectiveness, safety, and potential for patient adherence to the chosen medication. Use a local pharmacy to research the cost of the medication and provide the most cost-effective choice for the patient. Use great detail when answering questions 3-5.

Submission Instructions:

• Your initial post should be at least 500 words, formatted and cited in the current APA style with support from at least 2 academic sources.  Your initial post is worth 8 points.
• You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. Your reply posts are worth 2 points (1 point per response.)
• All replies must be constructive and use literature where possible.
• Please post your initial response by 11:59 PM ET Thursday, and comment on the posts of two classmates by 11:59 PM ET Sunday.
• Late work policies, expectations regarding proper citations, acceptable means of responding to peer feedback, and other expectations are at the discretion of the instructor.
• You can expect feedback from the instructor within 48 to 72 hours from the Sunday due date.

Title: Clinical Case Analysis of TM: A Dementia Patient

Introduction: This essay will analyze the case of TM, a 79-year-old man diagnosed with dementia six years ago. His wife, aged 72, is his primary caregiver and has observed a gradual deterioration in his condition, with recent increased hostility and aggression. TM also experiences hallucinations and wandering episodes. This paper will discuss the DSM-5-TR diagnosis, pharmacological and non-pharmacological treatment options, and assess their appropriateness, cost, effectiveness, safety, and potential for patient adherence.

Clinical Case Summary: TM’s clinical presentation is consistent with a neurocognitive disorder as per the DSM-5-TR criteria. His symptoms include cognitive impairment (gradual decline in memory and reasoning), behavioral disturbances (aggression and wandering), and perceptual disturbances (hallucinations). The duration of six years and the progressive nature of his condition align with the diagnosis of Major Neurocognitive Disorder (Dementia), likely due to Alzheimer’s Disease.

DSM-5-TR Diagnosis: Based on the information provided, the DSM-5-TR diagnosis for TM would be:

• Major Neurocognitive Disorder (Dementia), most likely due to Alzheimer’s Disease.
• With behavioral disturbance, given TM’s aggression and wandering.
• With hallucinations, as he experiences visual hallucinations.

Pharmacological Treatment and Rationale: Pharmacological treatment for dementia often focuses on managing symptoms and slowing disease progression. Given TM’s symptoms and diagnosis, two classes of medications are commonly prescribed:

1. Cholinesterase Inhibitors (e.g., Donepezil): These drugs improve cognitive function by increasing acetylcholine levels in the brain. They can help with memory and thinking. Considering TM’s fluctuating condition with periods of lucidity, Donepezil may be beneficial in enhancing his cognitive function during his calmer phases.
2. Atypical Antipsychotics (e.g., Risperidone): These medications can be used to manage aggression and hallucinations in dementia patients. However, their use should be cautious due to potential side effects. Given TM’s hostility and hallucinations, a low-dose antipsychotic like Risperidone may help manage his aggressive outbursts and reduce hallucinations.

Assessment of Pharmacological Treatment:

• Appropriateness: The choice of Donepezil and Risperidone is appropriate given TM’s specific symptoms. However, their use should be closely monitored.
• Cost: The cost of Donepezil can vary depending on the brand and dosage. Risperidone is relatively affordable. Generic versions may reduce costs.
• Effectiveness: Both medications can be effective in managing TM’s symptoms but may not halt disease progression.
• Safety: Risperidone use should be closely monitored for potential side effects, including extrapyramidal symptoms. Donepezil generally has a good safety profile.
• Adherence: Patient adherence may be challenging due to TM’s cognitive decline. Regular follow-ups and caregiver involvement are crucial.

Non-Pharmacological Treatment and Rationale (excluding psychotherapeutic modalities): Non-pharmacological interventions play a vital role in dementia care. In TM’s case, the following approaches can be beneficial:

1. Environmental Modifications: TM’s wife can make the home environment safer by removing potential hazards, installing locks or alarms on doors, and creating a structured daily routine to reduce confusion.
2. Behavioral Strategies: Implementing behavior management techniques, such as distraction, redirection, and positive reinforcement, can help manage TM’s aggression and agitation.
3. Caregiver Support and Education: Providing TM’s wife with education and support on dementia care can enhance her ability to cope with the challenges, reduce caregiver stress, and improve the overall quality of care.

Assessment of Non-Pharmacological Treatment:

• Appropriateness: These non-pharmacological interventions are appropriate and can complement pharmacological treatments.
• Cost: Costs are minimal and mainly involve making simple home modifications.
• Effectiveness: When combined with medication, these strategies can significantly improve TM’s quality of life and safety.
• Safety: Non-pharmacological interventions are generally safe, with minimal risk involved.
• Adherence: These approaches are likely to have high patient adherence as they involve adapting the environment and caregiver practices.

Conclusion: In the case of TM, a comprehensive approach to dementia care is essential. A DSM-5-TR diagnosis of Major Neurocognitive Disorder with behavioral disturbances and hallucinations is likely. The pharmacological treatment of Donepezil and Risperidone, along with non-pharmacological strategies, can help manage his symptoms and improve his quality of life. Regular monitoring, caregiver support, and education are crucial elements of TM’s care plan. Cost-effective generic medications and personalized interventions can be considered to optimize his treatment.