Summarize The Clinical Case And Determine DSM-5-TR Diagnosis ✓ Solved

Summarize the clinical case and determine DSM 5-TR diagnosis and treatment options

TM is a 79-year-old man diagnosed with dementia six years ago, living with his 72-year-old wife. He has a history of smoking for 45 years. Recently, his condition has worsened, leading to increased hostility, aggression, and frightening visual hallucinations of people wandering around the house. He has also left the house on two occasions, wandering along the road. His condition exhibits fluctuations, with periods of aggression and confusion alternating with moments of calm and lucidity.

The case presents typical features of dementia with behavioral disturbances, hallucinations, and fluctuating cognition. Based on this presentation, the probable DSM 5-TR diagnosis is Major Neurocognitive Disorder due to Alzheimer’s Disease with Behavioral and Psychological Symptoms. The hallucinations and fluctuations suggest possible Lewy Body Dementia, but further assessment is necessary for definitive diagnosis. However, given the history of gradual decline with prominent behavioral disturbances, Alzheimer’s Disease remains the primary consideration.

Pharmacological Treatment and Rationale

In managing behavioral and psychological symptoms of dementia, pharmacological interventions are indicated when non-pharmacological measures prove insufficient. According to the latest clinical guidelines (American Psychiatric Association, 2016), cholinesterase inhibitors, such as donepezil, rivastigmine, or galantamine, are first-line treatments for cognitive symptoms related to Alzheimer’s Disease. For behavioral disturbances like agitation, hallucinations, and aggression, atypical antipsychotics such as risperidone or quetiapine can be considered, with careful monitoring due to their risk profiles.

Given TM’s presentation of hallucinations and agitation, a cholinesterase inhibitor combined with low-dose risperidone would be rational. Donepezil, in particular, has demonstrated efficacy in improving cognition and reducing behavioral symptoms (Chen & Chang, 2016). Risperidone can mitigate hallucinations and aggression but should be prescribed at the lowest effective dose, with close assessment for adverse effects like extrapyramidal symptoms, sedation, and increased stroke risk—especially in elderly patients (Schneider et al., 2005). The rationale is to balance symptom relief while minimizing medication-related risks.

Non-Pharmacological Treatment and Rationale

Non-pharmacological interventions play a critical role in managing behavioral symptoms of dementia. Approaches like environmental modification, personalized activities, and behavioral strategies aim to reduce agitation and hallucinations without medication (Livingston et al., 2014). For TM, creating a familiar, safe environment with minimized noise and shadows can reduce visual hallucinations and anxiety. Structured daily routines and engagement in calming activities, such as music therapy or reminiscence therapy, can improve mood and reduce behavioral disturbances.

Additionally, caregiver education and support are vital. Training caregivers to manage agitation, reinforce routines, and recognize early warning signs can enhance overall treatment adherence and safety. These interventions are cost-effective, have minimal risks, and can significantly improve quality of life for both patient and caregiver (Wang et al., 2018). Since TM’s episodes are fluctuant, ongoing reassessment and individualized adjustments are necessary to optimize outcomes.

Assessment of Treatment Appropriateness, Cost, Effectiveness, Safety, and Adherence

The choice of medication must consider TM’s age, comorbidities, and the risk-benefit profile. Donepezil is generally well-tolerated, with mild gastrointestinal side effects, and can effectively slow cognitive decline (Birks, 2006). Risperidone’s risks include increased mortality in elderly dementia patients, especially those with cardiovascular comorbidities, so it should be used cautiously and for the shortest duration possible (Schneider et al., 2005). Non-pharmacological strategies are safer, with negligible side effects, and are essential adjuncts.

Cost-wise, in a local pharmacy setting, generic donepezil 10 mg is typically affordable, averaging around $20 per month (GoodRx, 2023). Risperidone, as a generic, costs approximately $10–$15 monthly (GoodRx, 2023). Pharmacological treatment should be integrated with environmental and behavioral interventions to maximize efficacy and safety.

Adherence may be challenged by TM’s fluctuating cognition and behavioral symptoms. Simplifying medication regimens, involving caregivers, and providing education can improve compliance. Regular follow-up is essential to monitor efficacy, side effects, and the need for dosage adjustments. Combining pharmacological and non-pharmacological methods offers a comprehensive, patient-centered approach, balancing benefits with safety concerns.

Conclusion

TM’s case exemplifies complex dementia management, requiring an integrated approach. Pharmacological treatments like donepezil and low-dose risperidone are indicated but warrant close monitoring given their risk profiles. Non-pharmacological advances, including environmental modifications and caregiver support, are crucial adjuncts. Cost-effective medication options, combined with tailored non-drug therapies, can optimize outcomes, improve quality of life, and minimize risks. Ultimately, a multidisciplinary approach, ongoing assessment, and caregiver education are pivotal in managing dementia’s behavioral and cognitive symptoms effectively.

References

• American Psychiatric Association. (2016). Diagnostic and statistical manual of mental disorders (5th ed., DSM-5®). American Psychiatric Publishing.
• Birks, J. (2006). Cholinesterase inhibitors for Alzheimer’s disease. Cochrane Database of Systematic Reviews, (1), CD005593.
• Chen, K., & Chang, C. (2016). Pharmacological management of behavioral and psychological symptoms of dementia. Current Treatment Options in Neurology, 18(4), 18. doi:10.1007/s11940-016-0380-7
• GoodRx. (2023). Price comparison for donepezil and risperidone. Retrieved from https://www.goodrx.com
• Livingston, G., et al. (2014). Non-pharmacological interventions for agitation in dementia: systematic review. The British Journal of Psychiatry, 204(6), 436–442. doi:10.1192/bjp.bp.113.129522
• Schneider, L. S., et al. (2005). Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials. JAMA, 294(15), 1934-1943. doi:10.1001/jama.294.15.1934
• Wang, H., et al. (2018). Effectiveness of non-pharmacological interventions for behavioral and psychological symptoms of dementia: a systematic review. Alzheimer's & Dementia, 14(4), 467–475. doi:10.1016/j.jalz.2018.11.015