Psychotic & Cognitive Disorders
Answer the questions below based on the following case study.
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.
- Summarize the clinical case.
- What is the DSM 5-TR diagnosis based on the information provided in the case?
- Which pharmacological treatment would you prescribe according to the clinical guidelines? Include the rationale for this treatment.
- Which non-pharmacological treatment would you prescribe according to the clinical guidelines? Include the rationale for this treatment excluding a psychotherapeutic modality.
- 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.
Expert Solution Preview
Introduction: In this case study, we will analyze the clinical presentation of TM, a 79-year-old man who has been diagnosed with dementia for the past 6 years. We will explore his symptoms, provide a DSM-5 TR diagnosis, suggest pharmacological and non-pharmacological treatments, and assess the appropriateness, cost, effectiveness, safety, and potential patient adherence to the chosen medication.
1. Summarize the clinical case:
TM is a 79-year-old man with a history of dementia for the past 6 years, living with his 72-year-old wife. His condition has gradually worsened, resulting in increased difficulty in managing him. He has become hostile, aggressive, and experiences visual hallucinations, causing fear and distress. There have been instances where he left the house unsupervised and was found wandering along the road. His condition fluctuates, with periods of confusion and aggression alternating with periods of calmness and lucidity.
2. DSM-5 TR diagnosis based on the provided information:
Based on the information provided, TM’s DSM-5 TR diagnosis would be Dementia with Lewy bodies (DLB). The key features include the gradual deterioration of cognitive functions, visual hallucinations, fluctuations in cognition, and recurrent complex visual hallucinations. The presence of parkinsonism symptoms, such as fine motor impairment or bradykinesia, is also commonly observed in DLB.
3. Pharmacological treatment and rationale:
The recommended pharmacological treatment for Dementia with Lewy bodies (DLB) is a cholinesterase inhibitor, specifically donepezil. Donepezil increases the availability of acetylcholine in the brain, which improves cognitive function and behavioral symptoms. It can help alleviate TM’s cognitive decline, aggression, and hallucinations. The dosage should be started low and gradually increased to the target dose, as tolerated.
4. Non-pharmacological treatment and rationale (excluding psychotherapeutic modality):
In addition to medication, non-pharmacological intervention plays a crucial role in managing DLB. One such treatment would be creating a structured and supportive environment for TM. This includes ensuring a consistent routine, minimizing distractions, and providing visual aids and reminders to help with orientation. Keeping the environment well-lit and reducing noise can also reduce the occurrence of visual hallucinations. Engaging TM in regular physical exercises, cognitively stimulating activities, and social interactions can help maintain his cognitive and functional abilities.
5. Assessment of treatment’s appropriateness, cost, effectiveness, safety, and potential for patient adherence to medication:
In terms of appropriateness, donepezil is a suitable choice for TM’s DLB, considering its beneficial effects on cognitive decline and behavioral symptoms. As for its cost, it would be ideal to research prices at local pharmacies to determine the most cost-effective option. Donepezil is available in generic forms, which are generally more affordable. In terms of effectiveness, it has shown efficacy in improving cognitive function and behavioral symptoms in DLB patients. Safety-wise, donepezil has a relatively good safety profile, with commonly reported side effects including nausea, diarrhea, and insomnia. Patient adherence may vary, but using a weekly pill organizer and providing clear instructions to the patient and caregiver can help improve adherence. Regular follow-ups and monitoring for side effects are also essential.
Additionally, for the cost-effective choice of donepezil, considering the local pharmacy prices, it is advised to research local pharmacies and compare the prices of different generic brands of donepezil to find the most affordable option for the patient. Detailed cost analysis should be conducted to ensure optimal affordability for TM and his wife.
To summarize, TM’s clinical case suggests a DSM-5 TR diagnosis of Dementia with Lewy bodies (DLB). Pharmacologically, donepezil is recommended due to its beneficial effects on cognitive decline and behavioral symptoms. Non-pharmacological interventions, such as structuring and creating a supportive environment, are crucial for managing DLB. The appropriateness, cost, effectiveness, safety, and patient adherence to donepezil should be considered, and local pharmacy prices should be researched to identify the most cost-effective choice for the patient.
