W12-Geriatric Case Study

Post#1

After assessing the patient, it is clear that she has bipolar I disorder and moderate dementia. The patient suffers from bipolar I disorder because she meets its criteria. According to the DSM-5 criteria, individuals with bipolar I disorder exhibit manic, hypomanic, and depressive episodes. Some of the hypomanic episodes exhibited by individuals with bipolar disorder include decreased need for sleep, increase in hyperactivity, and agitation. The patient in the case study has bipolar disorder since she is cantankerous and opinionated. Her caregiver also reports that she is, in most cases, agitated and oppositional. Besides, individuals with bipolar I disorder exhibits various hypomanic symptoms, including paranoia and expressing other aggressive behaviors (American Psychological Association, 2013). In the case study, the patient is paranoia in that when the caregiver is speaking on the phone; she believes that they are talking about her. Besides, she initiates arguments with other patients in the program, indicating that she is aggressive. Additionally, patients with bipolar I disorder exhibits various depressive moods characterized by low feeling, poor concentration, and lack of sleep (American Psychological Association, 2013). In this case study, the patient has been resisting sleep, staying up late, and waking in the middle of the night. Such symptoms indicate that the patient has bipolar I disorder.

On the other side, the patient has moderate dementia because she meets its criteria for diagnosis. According to the DSM-V criteria for diagnosis, individuals with dementia records a significant cognitive decline from a previous level of performance in one or more of the following cognitive domains; learning and memory, language, attention, perceptual-motor, and social cognition. In our case study, the patient records a significant decline in her memory and social cognition. When it comes to memory, the patient believes that whenever her caregiver is speaking on the phone, they are speaking about her. Besides, on social cognition, the patient cannot stay in the program without arguing with the other participants in the program. This shows that she has social deficits. Another essential aspect to consider is that cognitive deficits interfere with independence in everyday activities. In our case study, the patient's memory deficits have made it hard to get adequate sleep. Based on all the above aspects, it is evident that the patient also has dementia.

Tentative treatment plan

The provider should integrate both the medication and therapeutic interventions into the treatment plan to acquire excellent results. One of the medications that should be integrated into the treatment plan is Depakote. The provider should reduce the current 1500 mg Depakote daily dosage to 750 mg/d in divided dosages. In the treatment, Depakote is essential because it acts on GABA (γ aminobutyric acid) levels in the CNS to block voltage-gated ion channels and inhibit histone deacetylase (Stahl, 2017). This, as a result, help manage the severity of manic or hypomanic symptoms.

Additionally, the provider can incorporate Bupropion in the treatment plan. However, the provider should increase the dosage from 75 mg/day to 100 mg/day. When it comes to the dosage, the patient should start with an initial dose of 100 mg orally twice a day, which can then be increased after three days as per the patient progress. However, it should not exceed 450 mg/day. Bupropion should be incorporated in the treatment plan because it inhibits the reuptake of dopamine, serotonin, and norepinephrine, an action that results in more dopamine, serotonin, and norepinephrine to transmit messages to other nerves (Stahl, 2013). This, as a result, minimizes the patient’s depressive symptoms, such as lack of sleep, are managed. When it comes to Quetiapine, the provider can eliminate it from the dosage.

On the other side, to treat dementia, the provider can introduce another medication, Donepezil (Aricept). This medication is highly approved to treat all stages of the disease. The patient can start with 5 mg orally once a day in the evening before retiring to bed for the initial dosage. For the maintenance dose, the patient can have 10 mg orally once a day, after taking an initial dose of 5 mg once a day for 4 to 6 weeks. This medication is highly recommendable because it binds reversibly to acetylcholinesterase and blocks acetylcholine hydrolysis to increase the availability of acetylcholine at the synapses (Stahl, 2013). This, as a result, enhances an individual’s cognition, including memory and social interaction.

Apart from the medications, various therapeutic interventions such as CBT need to be integrated into the treatment plan. CBT involves trying to change an individual's patterns of thinking from negative to positive ones. In this scenario, CBT can help the patient identify her negative thoughts, emotions, and behaviors from negative to positive ones to live a more fulfilling life. CBT can help her understand how her negative thoughts lead to adverse behaviors such as aggression and how they can be managed (Ye et al., 2016). The sessions can be 16, with each taking an hour. Besides, a patient follow-up would be essential to consider in the plan; the first followed up can be in a week, then in two weeks as per the patient's progress. Finally, the patient can be referred to various individuals, including a psychiatrist and behavioral therapist, to manage her symptoms.

References

American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). (DSM-5). ISBN-13: 978-0-8904-2555-8.

Stahl, S. M. (2013). Stahl's essential psychopharmacology: neuroscientific basis and practical applications. Cambridge university press.

Stahl, S. (2017). Stahl's essential psychopharmacology prescribers guide (6th ed.). Cambridge University Press.

Ye, B. Y., Jiang, Z. Y., Li, X., Cao, B., Cao, L. P., Lin, Y., ... & Miao, G. D. (2016). Effectiveness of cognitive-behavioral therapy in treating bipolar disorder: An updated meta‐analysis with randomized controlled trials. Psychiatry and clinical neurosciences, 70(8), 351-361.