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GERIATRIC CASE STUDY
Post#2
Week 12 Discussion 1: Geriatric Case Study
Assessment
After a keen evaluation of the patient, she is suffering from Bipolar I Disorder and moderate dementia. The patient suffers from Bipolar I Disorder because she meets the criteria for its diagnosis. According to the DSM-5 criteria, in Bipolar I disorder, the manic episodes may be preceded by or may be followed by hypomanic or major depressive episodes. During the hypomanic episodes, there is increased energy or activity characterized by inflated grandiosity, racing thoughts, or flight of ideas (American Psychological Association, 2013). Hypomanic episodes are also characterized by distractively and excessive involvement in hazardous activities. In our case study, the patient is cantankerous and opinionated. The patient’s caregiver also reports that her behaviors are agitated and oppositional. Besides, according to the DSM-5 criteria, individuals with bipolar disorder present with manic episodes characterized by unreasonable euphoria, very intense moods, hyperactivity, and delusions (American Psychological Association, 2013). In our case study, the patient presents delusions; she refuses most cares and is paranoid that her caregiver is speaking about her whenever she is talking on a phone. The patient also argues with other participants in the day program such that she threatens to be sent out of the program.
Additionally, individuals with Bipolar I disorder present with depressive symptoms, including loss of happiness, lack of sleep, insomnia, and poor concentration. In our case study, the patient resisted sleep, staying up late, and waking in the middle of the night. Based on all these symptoms, the patient is suffering from bipolar I disorder.
Besides, the patient has moderate dementia because she meets its criteria for diagnosis. According to the DSM-IV criteria, individuals with dementia presents several cognitive deficits in addition to memory impairment. In various studies, memory impairment may be the only clinical finding, but it cannot be the only factor to consider when determining whether an individual has dementia (Groot et al., 2016). To affirm that an individual has dementia, one must portray deficits in social and occupational functioning, with the functional impairments portraying a decrease in the patient’s usual ability. In our case study, the patient displays multiple social functioning deficits. She refuses most care offered by the caregiver and is always oppositional to whatever information she provides. The patient also argues with the other participants in the program that she threatens to be kicked out of the program. With such symptoms, she has moderate dementia.
Treatment plan
The treatment plan incorporates all the pharmacotherapy and psychotherapy options that can help the patient manage the severity of the symptoms. To address the manic and hypomanic symptoms, the provider can continue Depakote. However, the patient should start with an initial dose of 750 mg/day PO in divided doses (Stahl, 2017). For the Depakote ER initial dose, the patient can take 25 mg/kg PO once daily. This can be increased as rapidly as possible to achieve the lowest therapeutic dose that provides desired clinical effect. However, it should not exceed 60 mg/kg/day. Depakote is an excellent medication to treat bipolar symptoms because it increases the concentration of gamma-aminobutyric acid (GABA) and inhibits histone deacetylase in the brain to minimize manic symptoms.
To manage the MDD symptoms, the provider can continue Bupropion. For the Immediate-release tablets, the patient can start with an initial dosage of 100 mg twice a day, which can then be increased, if necessary, after three days to 100 mg orally three times a day (Stahl, 2017). The maintenance dosage is 100 mg orally three times a day, and the maximum dosage is 450 mg/day in up to 4 divided doses. Single doses should not go beyond 150 mg. Bupropion inhibits norepinephrine and dopamine reuptake, resulting in more of these neurotransmitters in the brain. This minimizes depressive symptoms such as lack of sleep.
In addition, the provider can introduce another medication to address the dementia symptoms that the patient exhibits. A suitable medicine that can help address dementia is Aricept (Donepezil). When taking this medication, the patient can start with an initial dosage of 5 mg PO qHS, which can be increased to 10 mg qDay after 4-6 weeks if required) (Stahl, 2017). If the symptoms become severe, the dosage may be further increased to 23 mg/day after three months. Donepezil should be integrated into the plan because it would help reduce memory impairments and improve social functioning.
On the other side, Cognitive Behavioral Therapy (CBT) needs to be incorporated into the treatment plan to help the patient manage the symptoms. CBT is effective in patients with bipolar disorder because it decreases relapse rates. Besides, this medication improves mania/hypomania and depression symptoms and enhances the patient psychosocial functioning. CBT helps patients identify their negative thoughts, emotions, and behaviors and change them from positive to negative (Newman, 2021). This means that with CBT, the patient will be able to identify her aggressive behaviors, paranoia, and other negative thoughts and change them from negative to positive, eventually recovering from bipolar disorder.
Finally, the patient will be referred to other specialists such as family therapists to improve communication with other people, such as her caregiver. For the follow-up, the first one should be in a week, then in two weeks, depending on her progress.
References
American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). (DSM-5). ISBN-13: 978-0-8904-2555-8.
Groot, C., Hooghiemstra, A. M., Raijmakers, P. G., van Berckel, B. N., Scheltens, P., Scherder, E. J., … & Ossenkoppele, R. (2016). The effect of physical activity on cognitive function in patients with dementia: a meta-analysis of randomized control trials. Ageing research reviews, 25, 13-23.
Newman, C. F. (2021). Bipolar disorder. American Psychological Association.
Stahl, S. (2017). Stahl’s essential psychopharmacology prescribers guide (6th ed.). Cambridge University Press.
Psychiatric SOAP Note
Name: Luis S. Cabrera
Course Name: Adv.Psychopharmacology
Course Number: NU-643-03-21
Instructor’ Name: Nicole Walters
Institution: Regis College
Date of Submission: 11/19/2021
Psychiatric SOAP Note
|
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. |
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Objective |
Diagnosed with mild dementia and bipolar disorder
History of Violence to Self: None reported History of Violence to Others: Recent aggression and argument with colleagues at the daily program (mild) Auditory Hallucinations: None reported Visual Hallucinations: None reported Delusions: Thinks caregiver is talking about her on phone.
History of outpatient treatment: bipolar disorder and mild dementia Psychiatric hospitalizations: None reported Substance abuse treatment: None reported
None reported.
None reported.
Depakote 1500mg daily Bupropion 75mg qd Quetiapine 100mg qhs
Substance use: None reported Suicides: None reported Psychiatric diagnoses/hospitalization: Father’s dementia Developmental diagnoses: None reported
Lives in her own home with fulltime caregiver Currently attends a day program on weekdays
ROS noncontributory.
Orientation: A & O X 3 Appearance: The patient demonstrates nervousness including paranoia but dressed appropriately. Behavior: Cantankerous, agitated, oppositional Speech and language: Regular rhythm and tone and speaks in complete sentences. Attitude: Inattention Mood: Anxious Thought processes: Distracted Affect: Oppositional Suicidal ideation: No suicidal or homicidal ideations. Insight: Compromised |
|
Assessment |
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)
F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features (ICD10Data.com, 2020)
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). |
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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. |
References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.) (DSM-5). Washington, DC: Author.
Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66.
ICD10Data.com. (2020). The Web’s Free 2021 ICD-10-CM/PCS Medical Coding Reference. https://www.icd10data.com/
Jarvis, C. (2019). Physical Examination and Health Assessment E-Book. Elsevier Health Sciences.
López-Muñoz, F., Shen, W. W., D’ocon, P., Romero, A., & Álamo, C. (2018). A history of the pharmacological treatment of bipolar disorder. International journal of molecular sciences, 19(7), 2143.
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). London, England: Lippincott Williams and Wilkins.
CG&AM&BF_10/10/18
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.
Reply Posts Instructions
Please respond individually to at least two peers’ posts.
Read your peers’ posts and respond to at least two of your peers. In your post, critique the plan by answering the following questions:
1-Do you agree/disagree with the plan?
2-Is anything missing from the plan?
3-Compare your peers’ plan to yours – what are the advantages and disadvantages of each?
Your response should include evidence of review of the course material through proper citations using APA format.
***Important: Need at least one reply for Saturday before 10 pm Easter time
Please, send me the two documents separately, for example one is the reply to my peers Post#1, and the second one is the reply to my other peer Post#2.
-Minimum of 300 words per peer reply.
-Turnitin Assignment.
Background: I live in South Florida; I am currently enrolled in the Psych Mental Health Practitioner Program. I am a Family Nurse Practitioner working in psychiatric area.
