PMH/504 Week 7: Late-Life Psychiatry and Dementia-Related Behaviors, sample paper

Shouting at Sundown in the Memory Care Unit: Managing Agitation in an 84-Year-Old With Alzheimer Disease Using the DICE Approach Before Any Antipsychotic, and What the Mortality Data Require

[Student Name]

University of Phoenix

PMH/504: Psychiatric Management Of Adult And Geriatric Patients

Week 7 Assignment

[Instructor Name]

[Date]

The patient is a composite written for a model paper.

Mrs. W., 84, lives in a memory care unit with moderate Alzheimer disease. For three weeks, starting around 4 p.m., she shouts, paces, resists help with toileting and once struck an aide. Staff ask for "something to calm her down," suggesting quetiapine. The sections below follow a structured method from description to evaluation, then take up the medication question.

Background

Mrs. W. was a schoolteacher, widowed 10 years ago, and moved to memory care a year ago. Her Mini-Mental State Examination score is 14. She walks with a walker, has osteoarthritis of both knees and has had two urinary tract infections this year. She speaks little but still recognizes her daughter and enjoys music from the 1950s. Until three weeks ago, staff described her as pleasant and cooperative in the afternoons.

Describe

Kales et al. (2014), on behalf of a multidisciplinary expert panel, recommend the DICE approach for neuropsychiatric symptoms of dementia. The first step is to describe the behavior precisely: when it occurs, with whom, what precedes and follows it. Staff logs show that shouting begins in late afternoon, worsens during toileting with male aides and settles when her daughter visits. She says "No, no" and points to her stomach.

Investigate

Investigating causes includes the patient, the caregivers and the environment (Kales et al., 2014). Examination finds a firm, distended abdomen; she has had no bowel movement for six days. Her medication list includes oxybutynin, an anticholinergic, started for incontinence, and nightly diphenhydramine for sleep. Pain from arthritis is not treated. Late afternoon coincides with a shift change, a noisy dining room and fading light. Toileting by male aides may frighten her.

She pointed to her stomach; the answer was in the gesture before it was in the chart.

Ruling Out Delirium

A sudden change in behavior in a person with dementia requires a search for delirium. Her attention fluctuates more than usual, and her daughter says she seems "foggier." A urinalysis is negative this time, and basic laboratory tests show no electrolyte imbalance or infection. Constipation, anticholinergic drugs and pain are all known causes of delirium and agitation in older adults, so treating them may improve both.

Caregiver Factors

Staff are stretched at shift change, and toileting is often rushed. One aide reported feeling afraid of her after she struck him. Staff frustration and fear are part of the picture, and supporting them is part of the plan.

Create

The plan addresses each cause: treat constipation with a bowel regimen; stop oxybutynin and diphenhydramine, both anticholinergic and on the Beers list; start scheduled acetaminophen for arthritis; assign female aides for toileting when possible; reduce noise and increase lighting in the late afternoon; add a calm activity, such as folding towels, which she enjoys, at 3:30 p.m.; and schedule her daughter's calls in the evening. Staff are coached to approach from the front, speak slowly and offer simple choices.

Staff Training

A short huddle teaches staff the DICE steps and how to log behaviors. They learn to look for pain, hunger, toileting needs and fatigue before assuming that agitation is part of dementia. The aide who was struck is offered support and a change of assignment for toileting.

Hearing and Vision

Her hearing aids had been left in a drawer for a month. Staff now put them in each morning and check her glasses, since poor hearing and sight make care feel threatening in dim evening light.

Evaluate

Staff record episodes daily. After two weeks, shouting episodes have fallen from daily to twice a week, and there have been no aggressive incidents.

Pain Assessment in Dementia

Because Mrs. W. cannot reliably report pain, staff use an observational scale that scores breathing, vocalization, facial expression, body language and consolability. Her scores were highest during toileting and transfers, when her knees bear weight. After scheduled acetaminophen, her scores fell, and she accepted help with toileting more readily. Staff now give her a dose an hour before her evening care routine.

Sleep and Daylight

She had been napping for long stretches after lunch, then waking restless at night. Staff now take her outdoors or near a bright window in the late morning, keep afternoon naps under an hour and play her favorite music in the early evening. Her nighttime sleep has lengthened, and she is calmer at dusk.

The Antipsychotic Question

Pooling 15 randomized trials in people with dementia that compared atypical antipsychotics with placebo, Schneider et al. (2005) and found a small increased risk of death compared with placebo, concluding that the risk should be weighed against medical need and efficacy. The FDA added a boxed warning. Antipsychotics are therefore reserved for severe symptoms that cause danger or great distress and have not responded to other measures, used at the lowest dose for the shortest time.

Citalopram as an Alternative

Porsteinsson et al. (2014) randomly assigned patients with Alzheimer disease and agitation to citalopram or placebo, alongside psychosocial intervention, and found that citalopram reduced agitation and caregiver distress, with 40% moderately or markedly improved compared with 26% on placebo. However, citalopram was associated with worsening cognition and QT prolongation, limiting its use at the 30 mg dose studied. If Mrs. W.'s agitation had persisted despite addressing causes, low-dose citalopram with an ECG would have been an option to consider before an antipsychotic.

If an Antipsychotic Were Needed

If she became a danger to herself or others despite these steps, a low dose of an antipsychotic could be considered after discussion with her daughter, covering the mortality risk and the expected benefit. It would be reviewed within four weeks, with a plan to taper, since many residents can stop without the behavior returning.

Her Daughter

Her daughter holds health care power of attorney. She agrees with the plan, is relieved that causes were found and asks to be called before any new psychiatric medication is started.

Why the Drug Request Was Declined

Quetiapine might have sedated Mrs. W., but it would have left her constipation, pain and anticholinergic burden untreated, added fall and mortality risks and required ongoing reassessment. The DICE approach resolved most of the behavior without it. The logs continue for another month to confirm that the improvement lasts, and staff are asked to note any new trigger they observe, such as visitors, room changes or missed meals, and a follow-up visit is scheduled to review her bowel regimen, pain control and sleep now that diphenhydramine has stopped.

Conclusion

Mrs. W.'s evening agitation had identifiable causes: constipation, untreated pain, anticholinergic drugs, a noisy environment and frightening care routines. The DICE approach described, investigated, addressed and evaluated these, reducing her agitation without medication. Given the mortality risk of atypical antipsychotics and the cognitive and cardiac cautions for citalopram, drugs are reserved for symptoms that persist despite such a structured approach.

References

Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2014). Management of neuropsychiatric symptoms of dementia in clinical settings: Recommendations from a multidisciplinary expert panel. Journal of the American Geriatrics Society, 62(4), 762-769. https://doi.org/10.1111/jgs.12730

Porsteinsson, A. P., Drye, L. T., Pollock, B. G., Devanand, D. P., Frangakis, C., Ismail, Z., Marano, C., Meinert, C. L., Mintzer, J. E., Munro, C. A., Pelton, G., Rabins, P. V., Rosenberg, P. B., Schneider, L. S., Shade, D. M., Weintraub, D., Yesavage, J., & Lyketsos, C. G. (2014). Effect of citalopram on agitation in Alzheimer disease: The CitAD randomized clinical trial. JAMA, 311(7), 682-691. https://doi.org/10.1001/jama.2014.93

Schneider, L. S., Dagerman, K. S., & Insel, P. (2005). Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials. JAMA, 294(15), 1934-1943. https://doi.org/10.1001/jama.294.15.1934