Hospital emergency room by the police
A 74-year-old African American woman, Ms. Richardson, was brought to the hospital emergency room by the police. She is unkempt, dirty, and foul-smelling. She does not look at the interviewer and is apparently confused and unresponsive to most of his questions. She knows her name and address, but not the day of the month. She is unable to describe the events that led to her admission.
The police reported that they were called by neighbors because Ms. Richardson had been wandering around the neighborhood and not taking care of herself. The medical center mobile crisis unit went to her house twice but could not get in and presumed she was not home. Finally, the police came and broke into the apartment, where they were met by a snarling German shepherd. They shot the dog with a tranquilizing gun and then found Ms. Richardson hiding in the corner, wearing nothing but a bra. The apartment was filthy, the floor littered with dog feces. The police found a gun, which they took into custody. The following day, while Ms. Richardson was awaiting transfer to a medical unit for treatment of her out-of-control diabetes, the psychiatric provider attempted to interview her. Her facial expression was still mostly unresponsive, and she still didn’t know the month and couldn’t say what hospital she was in. She reported that the neighbors had called the police because she was “sick,” and indeed she had felt sick and weak, with pains in her shoulder; in addition, she had not eaten for 3 days. She remembered that the police had shot her dog with a tranquilizer and said the dog was now in “the shop” and would be returned to her when she got home. She refused to give the name of a neighbor who was a friend, saying, “he’s got enough troubles of his own.” She denied ever being in a psychiatric hospital or hearing voices but acknowledged that she had at one point seen a psychiatrist “near downtown” because she couldn’t sleep. He had prescribed medication that was too strong, so she didn’t take it. She didn’t remember the name, so the interviewer asked if it was Thorazine. She said no, it was “allal.” ‘Haldol?”, ask the interviewer. She nodded.
The interviewer was convinced that was the drug, but other observers thought she might have said yes to anything that sounded remotely like it, such as “Elavil.” When asked about the gun, she denied, with some annoyance, that it was real and said it was a toy gun that had been brought to the house by her brother, who had died 8 years ago. She was still feeling weak and sick, complained of pain in her shoulder, and apparently had trouble swallowing. She did manage to smile as the team left her bedside
evidence-based treatment plan. At all times, explain your answers.
1. Summarize the clinical case including the significant subjective and objective data.
2. Generate a primary and two differential diagnoses. Use the DSM5 to support the assessment. Include the DSM5 and ICD 10 codes.
3. Discuss a pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.
4. Discuss non-pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.
5. Describe a health promotion intervention that would be appropriate for this patient.
Sample Solution
Here's an evidence-based treatment plan for Ms. Richardson, addressing each point:
1. Clinical Case Summary
- Subjective Data: 74-year-old African American woman presented to the ER by police due to neighbor concerns about self-neglect. Reports of wandering, unkempt appearance, and foul odor. Patient is confused, minimally responsive, and disoriented to date, month, and location. Patient reports feeling sick, weak, shoulder pain, and difficulty swallowing. Denies current psychiatric symptoms (hallucinations, etc.) but admits past psychiatric treatment for insomnia (Haldol or similar). Claims gun found was a toy, belonging to deceased brother. Refuses to name a helpful neighbor.
- Objective Data: Unkempt, dirty, foul-smelling. Initially unresponsive, later minimally responsive. Disoriented to time and place. German Shepherd present at home (tranquilized by police). Apartment filthy, littered with dog feces. Gun found in apartment (taken into custody). Diabetes out of control.
2. Diagnoses
- Primary Diagnosis: Major Neurocognitive Disorder due to probable Alzheimer's Disease (F00/G30). This is supported by:
- DSM-5 Criteria: Significant cognitive decline from a previous level of performance in one or more cognitive domains (memory, language, executive function, etc.). Evidence of significant impairment in social or occupational functioning. The cognitive deficits do not occur exclusively in the context of delirium. The disturbance is not better explained by another mental disorder. Evidence of Alzheimer's disease based on the clinical presentation and cognitive decline.
- ICD-10 Code: F00
- Differential Diagnoses:
- Delirium (F05/R41.0): Due to uncontrolled diabetes, possible infection, or medication side effects (though unlikely given the long-standing nature of the reported symptoms). This needs to be ruled out first as it is a reversible condition.
- DSM-5 Criteria: Disturbance in attention and awareness. The disturbance develops over a short period of time and tends to fluctuate in severity during the course of the day. An additional disturbance in cognition (e.g., memory deficit, disorientation, language disturbance, visuospatial ability). The disturbances are not better explained by another preexisting, evolving, or neurocognitive disorder. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition.
- ICD-10 Code: F05
- Major Depressive Disorder with Psychotic Features (F33.3/F32.3): While less likely, the patient's withdrawal, confusion, and potential for misinterpreting information could mask underlying depression. The presence of a past prescription of an antipsychotic, even if for insomnia, could be indicative of a past psychotic episode.
- DSM-5 Criteria: Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The episode is not attributable to the physiological effects of a substance or another medical condition. The occurrence of the major depressive episode is not better explained by another disorder. There may be the presence of psychotic features.
- ICD-10 Code: F33.3
- Delirium (F05/R41.0): Due to uncontrolled diabetes, possible infection, or medication side effects (though unlikely given the long-standing nature of the reported symptoms). This needs to be ruled out first as it is a reversible condition.
3. Pharmacological Treatment
- Priority: Address the uncontrolled diabetes first. This is the most immediate threat to her health and could be contributing to her confusion. Insulin therapy and management of diabetic ketoacidosis (if present) are crucial.
- Neurocognitive Disorder: Cholinesterase inhibitors (e.g., donepezil, rivastigmine, galantamine) are the first-line treatment for Alzheimer's disease. They can modestly improve cognitive function by increasing acetylcholine levels in the brain. However, they do not halt the progression of the disease. Start low and go slow with dosing due to her age and potential for side effects. Monitor for nausea, vomiting, diarrhea, and bradycardia.
- Clinical Guidelines: Consult guidelines from the American Psychiatric Association or the National Institute on Aging for specific dosing and monitoring recommendations.
- Agitation/Psychosis (if present after addressing medical issues): If after stabilization of her diabetes, she continues to experience agitation or psychotic symptoms (hallucinations, delusions), consider a low-dose atypical antipsychotic (e.g., risperidone, olanzapine, quetiapine). These have a lower risk of extrapyramidal side effects than typical antipsychotics (like Haldol). Use with caution in elderly patients due to increased risk of cerebrovascular events and mortality.
- Clinical Guidelines: Again, consult relevant guidelines for safe and effective use in this population.
4. Non-Pharmacological Treatment
- Environmental Modification: Ensure a safe and supportive environment. Reduce clutter, provide adequate lighting, and maintain a consistent routine. This is crucial given her living conditions.
- Cognitive Stimulation: Engage her in activities that stimulate cognitive function, such as reminiscence therapy, puzzles, or simple games.
- Supportive Therapy: Individual or family therapy can provide emotional support and help her adjust to her cognitive decline. Given her isolation, addressing social support is vital.
- Occupational Therapy: An OT can assess her functional abilities and recommend strategies to maximize independence in daily living activities.
- Caregiver Support: Identify and support any caregivers involved. This may involve connecting them with resources, providing education, and offering respite care. If no family is available, exploring adult protective services or similar social support systems is essential.
5. Health Promotion Intervention
- Focus: Improving overall health and well-being, slowing disease progression, and preventing complications.
- Intervention: A multi-faceted approach addressing her physical and mental health:
- Diabetes Management: Education on diet, exercise, medication adherence, and self-monitoring of blood glucose. This is critical.
- Social Engagement: Encourage participation in social activities and connect her with community resources for seniors. Address social isolation.
- Cognitive Activities: Promote engagement in mentally stimulating activities.
- Fall Prevention: Assess fall risk and implement strategies to reduce falls (e.g., home safety modifications, exercise programs to improve balance).
- Regular Medical Checkups: Ensure she receives regular medical care, including monitoring of her diabetes, cognitive function, and mental health.
- Medication Management: Simplify her medication regimen if possible and ensure she understands how to take her medications correctly. Given the history of non-adherence to medications, this is a key component to address.
Important Note: This treatment plan is based on the limited information provided. A thorough assessment, including a detailed medical history, physical examination, and neuropsychological testing, is crucial for accurate diagnosis and individualized treatment planning. Collaboration with a multidisciplinary team, including physicians, nurses, social workers, and therapists, is essential for providing comprehensive care. Given Ms. Richardson's living situation and apparent self-neglect, Adult Protective Services should be contacted to ensure her safety and well-being.