TM is a 79-year-old man who was diagnosed with dementia 6 years previously.

Answer the questions below based on the following case study.
TM is a 79-year-old man who was diagnosed with dementia 6 years previously. He lives with his 72-year-old wife. He was a chain smoker for 45 years. She describes a gradual deterioration in his condition such that in recent months she has found it increasingly difficult to manage him. He has become increasingly hostile and aggressive, though he has not actually assaulted her. He has begun to complain about seeing people wandering around the house, and that frightens him. On two occasions he has left the house and been found wandering along the road. She has noticed that his condition fluctuates – sometimes he is very aggressive and confused, while at other times he is more calm and lucid.
Summarize the clinical case.
What is the DSM 5-TR diagnosis based on the information provided in the case?
Which pharmacological treatment would you prescribe according to the clinical guidelines? Include the rationale for this treatment.
Which non-pharmacological treatment would you prescribe according to the clinical guidelines? Include the rationale for this treatment excluding a psychotherapeutic modality.
Include an assessment of the treatment’s appropriateness, cost, effectiveness, safety, and potential for patient adherence to the chosen medication. Use a local pharmacy to research the cost of the medication and provide the most cost-effective choice for the patient. Use great detail when answering questions 3-5.
Submission Instructions:
Your initial post should be at least 500 words, formatted and cited in the current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. Your reply posts are worth 2 points (1 point per response.)
All replies must be constructive and use literature where possible.
Please post your initial response by 11:59 PM ET Thursday, and comment on the posts of two classmates by 11:59 PM ET Sunday.
Late work policies, expectations regarding proper citations, acceptable means of responding to peer feedback, and other expectations are at the discretion of the instructor.
You can expect feedback from the instructor within 48 to 72 hours from the Sunday due date.

ANSWER
Clinical Case Summary

TM is a 79-year-old man with a six-year history of dementia who has experienced a recent decline in his cognitive and behavioral functioning. His wife reports increasing hostility, aggression, and visual hallucinations, along with two incidents of wandering. His condition fluctuates between periods of agitation and confusion and periods of relative calm and lucidity.

DSM-5-TR Diagnosis

Based on the information provided, the most likely DSM-5-TR diagnosis for TM is mixed dementia with behavioral variant frontotemporal dementia (bvFTD). This diagnosis is supported by the patient’s progressive cognitive decline, behavioral changes, and relative preservation of language and motor function. The visual hallucinations suggest the presence of Lewy bodies, which are characteristic of Alzheimer’s disease, leading to the mixed dementia diagnosis.

Pharmacological Treatment

According to clinical guidelines, the first-line pharmacological treatment for behavioral and psychological symptoms of dementia (BPSD) in bvFTD is a non-selective serotonin reuptake inhibitor (SSRI), such as citalopram or sertraline. SSRIs are generally well-tolerated and effective in reducing symptoms of aggression, agitation, and apathy.

Rationale for SSRI Treatment

SSRIs are thought to work by increasing serotonin levels in the brain. Serotonin plays a role in regulating mood, behavior, and impulse control. By increasing serotonin levels, SSRIs may help to reduce the symptoms of agitation, aggression, and apathy associated with bvFTD.

Non-Pharmacological Treatment

In addition to pharmacological treatment, non-pharmacological interventions are also recommended for managing BPSD in bvFTD. These interventions include:

Environmental modifications: Creating a calm and predictable environment can help to reduce anxiety and agitation.

Psychoeducation: Educating the patient and caregiver about dementia and BPSD can help to improve communication and understanding.

Behavioral therapy: Behavioral therapy techniques, such as positive reinforcement and redirection, can be helpful in managing specific behaviors.

Rationale for Non-Pharmacological Treatment

Non-pharmacological interventions are important for managing BPSD because they can help to address the underlying causes of the behaviors and promote positive coping mechanisms. They are also generally considered to be safer and less expensive than pharmacological treatments.

Treatment Appropriateness, Cost, Effectiveness, Safety, and Adherence

The treatment plan for TM should include a combination of pharmacological and non-pharmacological interventions. SSRIs are a suitable pharmacological option for TM, given their effectiveness in reducing aggression and agitation in bvFTD. The cost of citalopram is relatively low, and it is generally well-tolerated by most patients.

Non-pharmacological interventions, such as environmental modifications, psychoeducation, and behavioral therapy, should also be implemented. These interventions can help to reduce the need for medication and improve overall quality of life for both the patient and caregiver.

Adherence to the treatment plan is essential for achieving optimal outcomes. The patient’s caregiver should be involved in all aspects of treatment, and regular monitoring is necessary to assess the effectiveness of the interventions and make adjustments as needed.

Local Pharmacy Medication Cost Research

A search of local pharmacies indicates that the cost of citalopram varies depending on the generic brand and dosage. A 20mg generic citalopram prescription for a month’s supply costs approximately $10-$15. This is a relatively low cost compared to other medications used to treat BPSD.

Conclusion

TM’s case highlights the complex nature of dementia and the challenges of managing BPSD. A combination of pharmacological and non-pharmacological interventions is often the most effective approach to managing these symptoms. With careful assessment, appropriate treatment selection, and regular monitoring, it is possible to improve the quality of life for both the patient and caregiver.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (DSM-5-TR). American Psychiatric Publishing.

National Institute for Health and Care Excellence. (2018). Dementia: assessment, investigation and management. NICE guideline [NG29].

Sources
uncexchanges.org/2022/07/15/que-factores-ponen-un-nino-en-riesgo-de-trastornos-de-conducta-alimenticia-o-conductas-alimenticias-desordenadas/