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MSGM Case Presentation February 2025

Title: Navigating the Challenges of Managing Behavioral and Psychological Symptoms in Dementia

Prepared by Dr Ng Tyng Sam

Supervised by Dr. Goh Cheng Beh


Mr. MA is an 80-year-old Malay gentleman with a history of hypertension.


Presenting Illness

He presented with worsening of aggressive behaviour for the past 1 week. He physically attacked his daughter and wife, breaking a glass, and his behaviour had become increasingly challenging to manage. The patient had also been verbally abusive, causing significant distress to his family members. On the day of admission, his daughter called the police, and he punched a police officer. He was then sent to the emergency department (ED) and admitted to the medical ward for abnormal behavior for investigation and to rule out organic causes. He was later referred to the geriatric and psychiatry team for managing his condition.


Chronological of event

Year 2020-2022


Cognition: The patients wife noticed repetitive questioning, misplacing items, and frequent forgetfulness. She also observed that he occasionally got lost while driving. Additionally, he reduced his participation in social events. However, there was no evidence of difficulty with communication or recognition. He was still able to celebrate festivals with his family.


Behavior/ Mood: She observed that he became anxious and occasionally accused others of stealing his money. Furthermore, he experienced visual hallucinations, seeing images outside his house, which sometimes caused irritation and agitation.


Instrumental Activities of Daily Living (iADL): The patients iADL was affected, as evidenced by his cessation of driving and reduced frequency of social activities. He still participated in prayers, although his wife had never checked on his praying steps. Additionally, he experienced difficulties managing banking tasks, which he described as “clumsiness”.


Basic Activities of Daily Living (bADL): The patients bADL remained intact, and he was able to walk independently without any assistance.


Year 2023-2024

Cognition: A further decline in his condition was noted, characterized by his inability to organize daily activities, continued memory deterioration, limited recognition of only his caregiver and their nicknames, and reduced of conversational engagement and festival celebrations.


Behavior/Mood: He began talking to himself (auditory hallucinations), although the content was unclear. He exhibited disorganized behavior, such as using a broom to shoot a dog, and experienced more frequent visual hallucinations, which caused him significant distress.


iADL: Impaired due to cognitive decline, requiring assistance from his wife.


bADL: He was able to feed himself with a spoon and use the toilet for urination and defecation. However, he required assistance with personal hygiene, and self-care activities had to be supervised.


Over the past four years, he has lived with his wife and unmarried eldest son in Mersing, Johor. Since his wife did not report any distress and his son was busy with his business, rarely participating in his care, they did not seek medical treatment as the patient's condition remained manageable. His relationship with his other children was not close, and with changes in his behavior and mood, they rarely visited him.


His eldest son moved to Abu Dhabi for work one month before his admission. The patient was then sent to live with his youngest daughter in Senawang for further care, as his wife began to feel stressed and could no longer manage his aggressive behavior. He was taken to KK Senawang for review, and an outpatient referral letter was given for further management at Hospital Seremban.


1 Week Before Admission

Cognition/ Behavior/ Mood: The patients cognition had worsened and continued to decline. He no longer recognized family members, had become more aggressive and abusive, and had started breaking glass and furniture in the house. He spoke irrelevantly and was unable to rationalize his actions.


iADL: Totally dependent.


bADL: Required assistance from one person for feeding and other daily activities. He also frequently soiled the house.


He was brought to the Specialist Clinic at Mahkota Medical Centre, where he underwent investigations, including blood tests and a CT brain scan. He was diagnosed with Lewy body disease, with a differential diagnosis of frontotemporal dementia. He was prescribed escitalopram, Exelon patches, and lorazepam as needed. However, his condition did not improve, and his behaviour became increasingly difficult to manage until the day he was brought to the ED by the police.


Social and personal history

He has 7 children, and his wife is 70 years old. He has had a history of hypertension for over 15 years and had been followed up at the KK Mersing, although he was non-compliant with the appointments and medications. During the transitional period when he moved to his youngest daughters house, he missed his hypertension follow-up appointments.


Care arrangement:


 Weekdays: He was cared for by his wife and youngest daughter.

 Weekends: He was cared for by his wife.


There was no history of childhood trauma or traumatic episodes. He studied up to Form 5 and previously worked in an oil palm factory, where he was promoted to supervisor before retiring at the age of 55.


Personality: Cheerful, very strict with his children, and hardworking.

Appetite: Mixed diet, not reduced


On Examination

The patient refused to open his eyes. He was on the 4-point restraint as he tried to get out of his bed

Talking incoherently and unable to obey command

Aggressive and verbally abusive

Appeared thin, with poor oral hygiene and dehydrated

Irritable when approached


Vitals: Blood pressure: 163/ 86 mmHg, pulse rate: 58 bpm, Spo2: 98% under room air, afebrile, reflo: 4.8


Assessment: 4AT score: 0+2+1+4. Mini Cog: 0. Pain AD score: 0. Cornell depression scale: 6.

Clinical frailty score: 6


Systemic examination was not remarkable.


Unable to perform a full neurological examination

No facial asymmetry, no dysarthria

Moving all limbs

No resting tremor

Agitated during neurological assessment


Investigations

Blood results during admission



ECG:



CT Brain:

  • No acute intracranial bleed.

  • Well-defined hypodensities at the anterior and posterior limbs of bilateral internal capsules, bilateral external capsules and left side of the pons in keeping with chronic lacunar infarct.

  • Bilateral periventricular hypodensities in keeping with small vessel ischemia.

  • Basal cistern, ventricles and cerebral sulci are prominent in keeping with cerebral atrophy.


MRI: an outpatient appointment


Questions

  1. What additional history would you like to obtain from the family members?

  2. What is your provisional diagnosis for the patient upon admission?

  3. What further investigations would you recommend during the patient's inpatient stay?

  4. How would you manage the patients aggressive behavior (both physical and verbal) during inpatient care?


Admission progression (19 days of hospitalization)

After the workup, following diagnoses were made:

  1. Major neurocognitive disorder (Likely mixed Alzheimer’s and vascular dementia) with Behavioral and Psychological Symptoms of Dementia (BPSD)

  2. Normochromic normocytic anaemia for investigation

  3. High-risk fall with multi-factorial causes (intrinsic and extrinsic)

  4. Bigeminy secondary to Ischemic Heart Disease

  5. Malnutrition, physical deconditioning and frail


The patient was co-managed with the psychiatry team during hospitalization. Only the youngest daughter visited the patient occasionally after office hours. Otherwise, the patient was alone, and the daughter was not attending caregiver training as she was pregnant. The patient was prescribed psychotropic medication to help manage his behavior.


Below is a summary of the psychotropics used:



Other medications given:

1) T. Cardiprin 1 tab OM

2) T. Atorvastatin 40 mg ON

3) Sy Multivitamin 10 ml OD

4) T. Ferrous fumarate 200 mg OD

5) T. Amlodipine 10 mg OM

6) T. Bisoprolol 2.5 mg OD

7) T. Calcium carbonate 500 mg BD

8) Laxatives - to ensure patient daily BO


Questions

  1. Will you initiate pharmacological treatment for this patient? If so, what approach will you take, and how will you manage psychotropic medications?

  2. How will you plan the patients rehabilitation?

  3. How will you communicate with the psychiatry team regarding the use of psychotropics to balance behavior control and rehabilitation goals?

  4. What steps will you take to reduce polypharmacy in this case?


Discharge Day



Discharge Destination: The patients daughter was reluctant to take him home, as his wife had already moved out and she was pregnant. Only the eldest son provided financial support, while the other children were unable to assist. However, the family had not yet decided on a permanent placement for him and planned to hire a caregiver.


Questions

  1. Given the limited family support, what do you anticipate will happen to this patient?

  2. What should be included in a comprehensive discharge plan for this patient?


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