Agitated Alzheimer’s Dementia
An agitated 72 year-old female with Alzheimer’s dementia. An agitated 72 year-old female with Alzheimer’s dementia.72 year-old female admitted to a skilled nursing facility following a fall and ankle fracture. She has a past medical history significant for hypertension, pulmonary emoboli for which she is on Coumadin indefinitely, and dementia. Her medication regimen includes Coumadin, hydrochlorothiazide, atenolol, aspirin, and Aricept. She is also on Calcium and Vitamin D supplementation. As is often the case with skilled rehabilitation, transferring records are often incomplete and/or erroneous and primary care records slow to obtain. During her stay she did well with physical and occupational therapy and within a week was ready to transfer home. I had significant concerns with regard to her cognition and ability to care for herself independently. Her POA listed was her son who I contacted and assured me that all was fine and that he would increase her supervision at home. I discharged her on a Thursday and within 12 hours she was readmitted to a local hospital having accidentally overdosed taking 4 days of medications in one sitting. She simply couldn’t remember if she had taken them, so kept on until the bottles were empty. Following this hospitalization she returned to our facility where I conducted in-depth cognitive testing and she presented with a moderate dementia of the Alzheimer’s type. I held a family meeting with her and her son, the POA and discussed with them not only my diagnosis but also the finding that she lacks the capacity to make decisions regarding her medical conditions as well as her finances. Fortunately, when she first presented with memory deficits to her PCP she drafted an enduring POA, her son. Her memory loss was profound. Physically, she continued to do well and quickly exhausted the scope of the second round of therapy and we had difficulty justifying her continued stay with insurance. Fortunately, she had resources and the son was able to arrange for 24-hour care at home. 72FemaleRPR neg, B12 neg, TSH normal, Lyme titer neg and Vitamin D level normal (thanks to the comments provided on previous discussions!). CT scan of the brain showing some hippocampal atrophy. Memory testing without spontaneous recall and none with categorical or forced choice prompts. Some minor executive function deficits. Aricept, Namenda, Zoloft.My question to the community-at-large concerns identifying various modalities or treatments for complications that occur with progressive Alzheimer’s dementia. Specifically, her memory impairment coincides with a dramatic lack of insight and a deep belief that nothing, in fact, is wrong with her. This occurs to the point where she becomes agitated and downright nasty at times with her family. I’ve worked with the family to educate them as much as possible regarding how to “pick your battles”, to avoid confrontation where possible and to redirect where able. In addition, she has difficulty sleeping, likely a combination of the anxiety produced by the progressive memory decline as well as the disease process itself. She is currently on maximum dose of Aricept and I’ve started Namenda. Her behavior continued to be an issue and improved with the addition of a low dose of an SSRI with the added benefit of some improved sleep. I anticipate some increased difficulty in the future with agitation and suspect a low threshold for adding a typical or atypical antipsychotic. I would desperately like to expand the armament of treatment modalities to my patients and families in the throes of this disastrous disease. UPDATE: 12/20/8. I’ve had some success with another patient with a similar presentation and but more of a sleep disturbance. His agitation and sleep improved greatly with low dose melatonin. It’s become more integrated in my armament.