How I Treat: Addressing Cognitive, Functional, and Behavioral Changes in Late-Stage Alzheimer Disease Case Presentation
The Case:
The patient is an 81-year-old married man and retired accountant who was diagnosed with Alzheimer disease 8 years ago and is now at an advanced stage with significant, global neurocognitive impairment, functional decline requiring 24/7 assistance with all ADLs, and living in a memory care center at an assisted living facility. He makes relatively good eye contact and attends to contact with others, but his aphasia makes it difficult to communicate coherent verbal information or responses. He is ambulatory but unsteady and refused to use a walker or sit in a wheelchair. Sleep is variable and he will often wake up at night and wander the hallways, sometimes intruding into other resident’s rooms. Increasingly, he is trying to get into bed with other residents and has become aggressive with staff when they try to remove him. The nursing director has told his wife that if these behaviors do not improve they will need to discharge him.
His primary care physician initially started him on temazepam 15 mg at bedtime which calmed him but made him groggy, and on several occasions he was found staggering in the hallways and bumping into furniture. The temazepam was switched to alprazolam 0.5 mg without any improvement, and then 1 mg with the same outcome as the temazepam. After falling in the hallway and hitting his head, the alprazolam was stopped and a psychiatry consult was called. A medical work-up including a head CT did not show any acute medical problems or head injury.
When seen by the psychiatrist, the patient was unable to provide any coherent history, but his wife reported that he was a chronic insomniac and often stayed up late in the past watching TV or puttering around the house. She also noted that they had a very close marriage and never were separated over nearly 50 years until he was admitted to the center.
