W12-Geriatric Case Study

Criteria

Clinical Notes

Subjective

Patient is paranoid and complains that her caregiver is talking about her when on the phone. Patient has become extremely argumentative with her counterparts in the daily program and is at risk of being kicked out.

Patient has demonstrated agitated and oppositional behaviors in the recent past.

Patient also resisting sleep and wakes up in the middle of the night.

Patient is opinionated and cantankerous at baseline.

Patient has a positive history of moderate dementia and bipolar disorder.

Objective

Past psychiatric history:

Assessment

Differential diagnosis:

1. Dementia ICD-Code F03. 90 – Senile dementia with paranoia

2. F31.9 Bipolar disorder, unspecified

3. F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features

(ICD10Data.com, 2020)

Primary diagnosis:

F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features (ICD10Data.com, 2020)

Treatment options:

Patient is refusing treatment options provided presently.

Priority symptoms:

Apathy – Patient demonstrates oppositional tendencies and agitation which are the debilitating behaviors that are likely to affect the care plan. Medication adherence is critical in management of bipolar disorder (Jarvis, 2019).

Paranoia - The patient’s relationship with her caregiver is critical to her quality of life. The paranoia tendencies demonstrated by the patient’s concerns that her caregiver is talking about her when on phon. The paranoia is likely to trigger conflict and destabilize the caregiver-patient relationship further compromising the care process (American Psychiatric Association, 2013).

Unstable sleep patterns - Insufficient sleep significantly affects mood and can trigger the bipolar and dementia symptoms. The patient’s behaviors of resisting sleep, waking up in the middle of the night, and staying up late are likely to compromise the patient’s mood and affect the treatment plan.

Poor social skills – The patient has been identified as being argumentative in the day program especially with colleagues. The treatment options available for the patient are likely to include group cognitive behaviors and with the poor social skills the goals of treatment option are likely to be unattained (American Psychiatric Association, 2013).

Plan

Bupropion: The medication will be changed from the current 75mg qd to Extended release 174mg once daily in the morning. The patient already demonstrates resistance to medication and increasing the interval of taking medication could help in improving adherence. The medication will be sustained for the next four weeks upon which a review will be accomplished (López-Muñoz et al., 2018).

Depakote: The medication is purposely integrated to help manage the possible manic symptoms associated with bipolar. The manic symptoms have not been prevalent recently based on chief complaints described. Thus, the current dosage at 1500mg daily will be maintained as it has already been therapeutic in recent days. The medication will be sustained for 4 weeks (Sadock et al., 2015).

Risperidone: The medication will replace quetiapine. Quetiapine has not been effective in stabilizing the patient’s sleep patterns. Risperidone 2mg once daily will be maintained. The reluctance to increase the quetiapine dosage beyond 100mg is informed by the possibility for extreme side effects especially related to risk for diabetes, weight loss, and cardiovascular diseases (López-Muñoz et al., 2018).

Lorazepam 0.25mg once daily: The medication will be introduced to help manage the agitation and oppositional behaviors. The current debilitating behaviors with the patient are related to agitation because they compromise social skills, medication adherence, and relationship with the caregiver (López-Muñoz et al., 2018).

Non-pharmacological

Group cognitive-behavioral therapy: The patient social skills are significantly compromised. The inability to sustain reasonable social interactions at the day program demonstrates the level of compromise and this is extended to the poor relations with the caregiver. The group CBT program will help in improving the patient’s interactions with the social environment. Importantly, the group CBT will help the patient develop a sense of belonging and gradually help in controlling the suspicions with the people in their environment. The CBT program will be maintained for 12 weeks (Carvalho et al., 2020).

Interpersonal therapy: This is an adaptive therapy that seeks to help the patient redevelop effective relations especially with the relevant people around them. In this case, the sessions will be conducted in the company of the patient and their caregiver. The intention is to improve the relationship between the two by first improving the trust levels and secondly helping control or eliminate the paranoia and suspicion. The interpersonal therapy sessions will be sustained for 12 weeks and will run alongside the CBT (Carvalho et al., 2020).

No lab tests will be ordered for the patient.