Neurology

PCP submission

82 year old female with PMHX notable for: pacemaker, aortic stenosis, atrial fibrillation, Gerd, bowel and bladder incontinence, major depression with anxiety, CHF, hyperlipidemia, degenerative disc disease with sciatica. Patient’s daughter daughter reports that patient has been more agitated, aggressive, restless, seeing people who are not there. She was not sleeping, started her on Trazodone and family reports that she is now sleeping and getting 8 hours a night. but behaviors continue. Patient had a fall a couple weeks ago with a large hematoma to the left maxillary. PPt has also been treated for a UTI and is some better but still having the reported behaviors. This is the regimen she was on before I took over her care. would appreciate any recommendations.

Current medications:

atorvastatin 10 mg PO QHS

gabapentin 300 mg PO TID

Protonix 40 mg PO daily

BuSpar 15 mg PO BID

Lasix 20 mg PO daily

Potassium chloride 10 M EQ PO daily

Eliquis 2.5 mg PO BID

lisinopril 30 mg PO daily

trazodone 75 mg PO QHS

Labs were redrawn today. I have attached the most recent labs that are available 

PCP Question: Can you provide treatment recommendations on my patient given current condition and recent behavioral changes?

Specialist response

Thanks for the consultation and background. A number of things come to mind as considerations: The sleep improving is a very good development and does imply a trajectory of continued improvement -the persistent of symptoms likely warrants additional intervention-at least in the short-term -addressing the low Vitamin D will likely help, at least somewhat, longitudinally -given the history of psychotic sx, even if in the context of a possible delirium, the sx warrant treatment with an antipsychotic since behavior is being affected which tips the risk-benefit in favor of treatment-even if treatment may not be necessary long-term e.g. Seroquel 25mg to 50 mg HS (this may even be in place of Trazodone to minimize polypharmacy) and the dosing could be increased based upon sx response the Seroquel could be discontinued once the UTI has fully resolved however, if the psychotic sx persist, then longitudinal treatment will have to be reconsidered would have to continue monitoring lipid/glucose metaboliem and observing for any emerging movement disorder with the AIMS (abnormal involuntary movement scale) -given the history of reported depression-I’ve attached a screening instrument (Cornell scale) for depression in dementia Mirtazapine 7.5mg to 15mg HS could replace the Trazodone and the Buspar if this option is pursued -also i’ve attached a screening instrument(Addenbrooke) to help further assess the cognitive symptoms in some instances treatments (E.g. Aricept and/or Namenda) may help with other symptoms (behavior, psychotic sx) even if cognition is not appreciably improved-you would have to assess cardiac rhythm if leaning toward Aricept -reassessing the Buspar -given the overall context may be relevant- especially if an anti-depressant is going to be initiated. Below is the website of the Alzheimer Association which is a good resource. There may be a role for respite care and/or day treatment which they can help identify-they can be a resource for the family also -https://www.alz.org/ Thanks again