How I Treat Alzheimer With Agitation: Complex Case With Shifting Triggers Case Presentation
The Case:
The patient is an 88 year-old long-divorced woman living in a nursing home for the past year, having been transferred there after a hospitalization for syncope, delirium, and an associated urinary tract infection. Nurses reported being very frustrated with her chronic behaviors of irritability, agitation, and accusations towards them. For example, she would often refuse to leave her room, and rarely went to any activities or the dining room. She frequently accused staff of running a criminal enterprise and stealing from her. She would often yell at staff and insult or threaten them. She cried uncontrollably during the day at times. Her sleep was poor and she reported having nightmares. This patient also had a history of poor short-term memory which was getting worse over the past year, and had been diagnosed with Alzheimer disease prior to admission.
Her primary care physician had started her on venlafaxine without any improvement, and then switched to escitalopram 10-mg with trazodone 100 mg at bedtime, but her symptoms persisted. She was also on alprazolam 0.5 mg as needed for anxiety and agitation, a rivastigmine 9.5 mg patch, and memantine 10 mg twice daily.
When seen by the psychiatrist, the patient came with her granddaughter, as she was estranged from her two sons and other family members. Her granddaughter described her as chronically unhappy, volatile, and generally unpleasant to deal with, which is why most family members would not have anything to do with her. The granddaughter, however, had a good connection with her and really felt that she was suffering and needed more help. She described her as a wonderful musician who once sang as a soprano in many opera productions.
The patient presented with a downcast and somewhat withdrawn demeanor and could not provide much history about herself. She became more animated during the interview and described feeling lonely and nervous. She also reported having a lot of back pain which was, at times, excruciating. That is why she spent so much time in bed, she reported, as well as to keep an eye on her possessions so that they would not be stolen. Her affect was anxious, constricted, and irritable. She was alert and oriented to person, place, and partially to time, and scored 18 out of 30 on the Mini-Mental State Examination.
In addition to her back pain, related to degenerative disease in her spine, the patient has chronic kidney failure, cardiomyopathy, hypertension, GERD, and frequent urinary tract infections. She also has moderate hearing loss and macular degeneration.
