CASE STUDY:

The first noticeable symptoms of illness shown by this 51 year-old woman was suspiciousness of her husband. Soon a rapidly increasing memory impairment became evident; she could no longer orient herself in her own dwelling, dragged objects here and there and hid them, and at times, believing that people were out to murder her, started to scream loudly.

On observation (3 weeks) in the psychiatric care unit. Her entire demeanor bears the stamp of utter bewilderment. She is completely disoriented to time and place. Occasionally, she remarks that she does not understand anything and states that she is "at my wits’ end". Sometimes she greets the doctor as if he were a visitor and excuses herself that she has not finished with her work; on other occasions, she screams that her doctor wants to cut her open; on other times yet, she dismisses her doctor, full of indignation and with expressions indication that she fears the doctor is threat to her safety. At times (usually evenings) she is totally delirious, drags her bedding around, calls for her husband or daughter, and seems to have auditory hallucinations. Often she screams for many hours in a horrible voice.

With her inability to understand her situation, she bursts into loud screams each time she is approached to be examined. Only through constantly repeated efforts was it possible to eventually establish some limited information.

Clinical/Evaluation:

Her ability to process information is most severely disturbed. If one shows her objects, she usually names them correctly. Immediately thereafter, however, she has forgotten everything. In reading, she confuses lines, reads by spelling, or with senseless intonation. When writing, she repeats single syllable words many times, omits other words and gets stuck altogether very quickly. When speaking, she frequently uses phrases indicating perplexity or embarrassment, or single paraphasic expressions (milk pourer instead of cup); sometimes one observes that she is completely at a loss for words. She clearly does not grasp some questions, and it seems that she no longer knows the use of certain objects. She sometimes needs help with ADL’s such as dressing, and bathing. Although, she is not incontinent; sometimes she requires assistance in the bathroom.

Her gait is normal, and she can use her hands well. Patellar reflexes are present. Pupils react. No cardiac enlargement. Vital signs WNL. Weight 110lbs, HT 5’6". Laboratory findings indicate: hypoalbumenemia, Thyroid profile WNL, CBC WNL, Urinalysis WNL, RPR (syphilis) negative, B-12, Folate, thiamine levels WNL, Current Medications: Haloperidol 5mg po bid, Benztropine Mesylate 2mg po bid, Imipramine 50mg po q hs. Lorazepam 1mg po/IM every 4 - 6 hours as needed for agitation. Propranolol Sustained-Release 120mg po qd, Glipizide 10mg po q am.

Axis I: Possible Alzheimer’s Dementia, R/O Major Depression with Psychosis

Axis II: deferred

Axis III: Hypertension, Type II; Diabetes, Postmenopausal, Significant weight loss/hypoalbumenemia

Axis IV: Moderate - Severe: Over the past 3 months her husband has had increasing difficulty caring for her by himself. Last summer, she was forced to retire early from her position as a high school English teacher.

Axis V: GAF 30 - 40

Physician’s order: Psychopharmacy Consultation to assess the patient’s increase in agitation and behavioral/psychiatric symptoms.

1. Assessment/Assumptions (8 points: 20 percent of grade):

A. Describe the previous psychiatric history of the patient: Answer: No documented history of admission or psychiatric treatment. Although, recently was forced to retire early because of increasing difficulty developing lesson plans and lecturing to students.

B. Is there any evidence of Major Depression causing current and/or past impairment of function? Answer: Possible. The husband was able to confirm that his wife was having frequent crying spells shortly after receiving the news of her early retirement. The crying spells did diminish in frequency over a period of 2 months. No medical treatment was sought. Currently, the patient is difficult to interview so it is difficult to assess.

C. Name the medications and reactions the patient has had to medications: Answer: The patient is not allergic to any medications.

D. How long has she been treated with haloperidol and benztropine? Answer: The patient was started on haloperidol and benztropine shortly after admission on the psychiatric unit and has been on the haloperidol/benztropine for approximately 2 weeks. She is compliant with treatment.

E. When was the imipramine started? Answer: Imipramine was started 1 week ago because of the patient’s difficulty falling asleep and crying and screaming at night. Is this medication effective in improving sleep? Answer: Patient tends to continue to become increasingly disorientated in the evenings especially after the evening and bedtime medications.

F. How much lorazepam is administered to the patient? Answer: For the past week the patient received up to 3 doses/day of lorazepam because of anxiety and agitated behavior. Is this medication effective in decreasing symptoms? Answer: Initially the patient becomes quiet because of the drowsiness side effects; however, she becomes agitated after the medication wears off.

G. How long has the patient been treated for hypertension and diabetes? Answer: The patient has been treated with the long acting propranolol and glipizide for the past 3 years. How effective has the treatment been for the patient? Answer: Currently these medications have controlled symptoms and she appears to tolerate these with no complaints of side-effects.

H. How much weight has the patient lost over the past 6 months? Answer: She has lost approximately 20 lbs. over the past 6 months. Three years ago she was 160 lbs. Currently, her weight is stabilized and she has been eating over 50% of her meals with some prompting.

I. After discharge, what will be the needs of her husband to care for his wife? Answer: The husband decides he wants his wife to be at home with his family.

2. Problems (8 points)

A. The anticholinergic effects of Benztropine and Imipramine can negatively affect her memory and cognitive function leading to an increased level of agitation.

B. The antipsychotic haloperidol has not demonstrated any mild or moderate improvement (over 3 weeks) in the patient’s delusional thinking or agitated behavior and may be possibly worsening agitated symptoms.

C. The patient’s possible depression is not being adequately treated. We are unable to use a therapeutic dose of imipramine because of side-effects.

D. Benzodiazepines can adversely affect the patient’s memory and cause disorientation and confusion in patients with dementias.

E. The patient is postmenopausal and is not currently treated with estrogen replacement therapy.

F. Propranolol has been implicated in causing depressive symptoms.

G. The patient is not on any antioxidant or NSAID therapy.

H. The patient is a good candidate for AChEI therapy if the husband wishes to take care of his wife at home.

3. Intervention goals (Outcome) (8 points)

A. Patient will be less agitated and delusional over the next 1 - 2weeks.

B. The patient will have improved quality of sleep at night with minimal daytime sedation within the next week.

C. Extend the patient’s ability to live at home by delaying the rapid cognitive/memory decline over the next 4 - 6 months.

D. Continue to have good control of hypertension and diabetes.

4. Treatment (8 points)

A. Discontinue haloperidol, benztropine, and imipramine. Reason: to minimize the anticholinergic properties and lack of efficacy.

B. Consider starting Olanzapine 5mg po q hs. Consider increasing Olanzapine to 5 -10 mg q hs, if there is little response in 2 weeks. Reason: An atypical antipsychotic agent such as olanzapine can improve cognitive function in the frontal cortex (5HT-2 inhibition) and minimize the side-effects of Tardive dyskinesia and restlessness/agitation caused by akathisia. In addition, Olanzapine is sedative and may provide treatment for insomnia-like symptoms.

C. Consider quickly tapering lorazepam over next 5 - 7 days. Decrease dose by 1mg every other day until discontinued.

D. Considering starting antidepressant such as Venlafazine XR 37.5mg/day and titrating up to 75mg/day. Reason: Venlafaxine was selected because of maybe less drug interactions and dual activity in blocking re-uptake activity of serotonin and norepinephrine.

E. Consider starting Donepezil 5mg po q hs and slowly titrate over 1 week to 10 mg po q hs. Reason: Discussed benefits/risk to husband and consented to give donepezil a 6 week trial and then reassess need for continuation.

F. Consider starting Vitamin E 400 i.u. tid with meals. Reason: (antioxidant effects)

G. Consider starting Conjugated Estrogen 0.625mg po q am. Reason: (neuroprotective)

H. Consider changing propranolol SR to Nifedipine XR 30mg po qd. Reason: To minimize possible CNS depression with propranolol. Also Calcium Channel blockers may be helpful in decreasing neuronal cell death. (NOTE: This is highly theoretical and unproven in clinical trials.)

I. Consider adding Ensure (nutritional supplement) to patient’s diet to encourage weight gain.

J. Implementation of a behavioral program and nonpharmacological approaches to handle the agitated patient.

K. Obtain Neurology consultation to rule out other cognitive disorders.

5. Follow-up (8 points)

A. Monitor for muscarinic side-effect symptoms from donepezil such as sweating, drooling, diarrhea, and (EPS) muscle spasms.

B. Monitor for changes in psychiatric and behavioral symptoms.

C. Monitor for side-effects from the Olanzapine and Venlafaxine

D. Monitor vital signs q shift changes and monitor Accu-checks (serum glucose) levels two times a day.

E. Monitor body weights one/week.