Acute Behavioral Disturbance in a New Resident with Cognitive Impairment
Patient Name: Mr. Z
MRN: XXX
Date of Service: 02-05-2024
Start Time: 11:45 End Time: 12:30
Billing Code(s): 99483
Accompanied by: Family members
CC: The patient has been displaying behavioral and psychological symptoms associated with the onset of Alzheimer’s disease, including confusion, physical aggression, and paranoia
HPI: The patient has a history of Alzheimer’s disease. He was presented to the emergency department (ED) after displaying aggressive and paranoid behaviors at home. The ED workup was unremarkable, and he was admitted to a long-term care facility in the Alzheimer’s Unit. Mr. Z has since then been wandering around, exhibiting verbal aggression, depression, and attempts to leave.
S-
Crisis Issues: The patient is easily agitated, physically aggressive, depressed, wanders aimlessly, and has shown a risk of absconding.
Reviewed Allergies: NKDA
Current Medications:
- Donepezil 5 mg PO HS
- Prazosin 1 mg PO HS
- Crestor 20mg PO at HS
ROS: Poor
O-
Vitals: T: 98.8, P 88, R 18, BP 132/78
PE:
Constitutional: Occasionally agitated, noncooperative, rapid and confused speech, and hyperactive
Neuro: The patient is disoriented to place and time, an unsteady gait.
Head: Normocephalic, atraumatic
Cardiac: RRR, no murmurs noted
Lungs: CTA A/P
MSE:
Mr. Z, a 68-year-old male appears notably agitated, inattentive, and distracted. He is restless, is verbally aggressive, and has been reported to be physically aggressive towards his family members. He is disoriented to place and time. His thought process is disturbed and has paranoia and thinks he is being harmed. He has a depressed affect and threatens to burn his house down.
A – with (ICD-10 code)
Differential Diagnoses:
- Alzheimer’s disease with behavioral and psychological symptoms-ICD-10 code: F02.81
- Major Neurocognitive Disorder, Unspecified, with behavioral disturbance-ICD-10 code: F01.9
- Delirium- ICD-10 code: F05
Definitive Diagnosis:
Alzheimer’s Disease with behavioral and psychological symptoms-ICD-10 code: F02.81.
P- The client is expected to continue with current medications as well as other counseling therapy.
Care Plan
Non-pharmacological Tx: Cognitive behavioral therapy (CBT)
Pharmacological Tx: Besides the current medications, the patient will add escitalopram 10 mg PO daily to help manage depression and agitation.
Education: The patient and his family will be educated on coping skills, medication management, and adherence. The patient will also be educated on possible side effects and harm, drug interactions, and drug reactions.
Follow-up: The patient was admitted to the facility and requires regular checkups on his progress.
Referrals: None at this time
Additional Instructions for Staff for Medication and Monitor Patient
The nurse is expected to continuously monitor and identify any changes and administer medications strictly as prescribed. The nurse administering the medication needs to monitor any side effects and report such incidents of drug reactions and patient harm to the PMHNP. Error reporting in nursing helps to significantly reduce the occurrence of medication errors later (Härkänen et al., 2020). Mr. Z is currently on Donepezil 5 mg PO H, and, Prazosin 1 mg PO, Crestor 20mg PO at HS. His newly diagnosed medication is escitalopram. Based on the evidence of a randomized, controlled, multicenter clinical trial, escitalopram is an effective medication for managing depression and chronic agitation in patients with Alzheimer’s disease (Ehrhardt et al., 2019). Escitalopram will be administered at a daily dose of 10 mg through the mouth daily. The administering nurse is expected to issue a notification before administering the medications for verification. Additionally, the nurse must visually see the patient, confirm their name and admission number, and their current health status before administering the medication.
For better patient safety, the nurse is required to regularly monitor the patient after any medications have been administered to check for side effects and efficacy. Furthermore, the administering nurse is expected to document all medications administered including dosage, frequency, side effects, and any other patient responses to the medication. It is important to note that escitalopram is not considered a chemical restraint as it is used for the specific management of mood disorders.
References
Ehrhardt, S., Porsteinsson, A. P., Munro, C. A., Rosenberg, P. B., Pollock, B. G., Devanand, D. P., Mintzer, J., Rajji, T. K., Ismail, Z., Schneider, L. S., Baksh, S. N., Drye, L. T., Avramopoulos, D., Shade, D. M., Lyketsos, C. G., Munro, C., Lee, H., Bienko, N., Shade, D., … Teodoro, L. (2019). Escitalopram for agitation in Alzheimer’s disease (S-CitAD): Methods and design of an investigator-initiated, randomized, controlled, multicenter clinical trial. Alzheimer’s & Dementia, 15(11), 1427–1436. https://doi.org/10.1016/J.JALZ.2019.06.4946
Härkänen, M., Turunen, H., & Vehviläinen-Julkunen, K. (2020). Differences between methods of detecting medication errors: A secondary analysis of medication administration errors using incident reports, the global trigger tool method, and observations. Journal of Patient Safety, 16(2), 168–176. https://doi.org/10.1097/
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Question 
Read the case study below.
Complete a SOAP Note on the patient. (In your SOAP note: Give an example of documentation for the PMHNP provider; (include prescription details as well as instructions for staff to give medication and monitor patient))
In your SOAP note, design a treatment plan that includes PRN medications in case the patient continues to be agitated.
Acute Behavioral Disturbance in a New Resident with Cognitive Impairment
Answer the questions listed below:
- What medications would you prescribe? Why?
- What doses?
- Would you have these listed as standing orders for the nursing home staff or would you want to be notified before given to verify and determine the need?
- Would you want to visually see the patient before having the medications given?
- What monitoring would need to be provided after medication is given?
- What documentation would need to be provided and how often for the medication to be continued?
- Would the medication be considered chemical restraints? Why or Why not?
Please see the template provided to guide your writing of SOAP notes.
Crisis Intervention and Safety Planning for the Adult/Geriatric Patient
Mr. Z, age 68, is a new resident of a long-term care facility in the Alzheimer’s Unit. He was recently taken by his family for evaluation in the Emergency Department after he was found to be confused, physically aggressive with family members, threatening to burn the house down, and paranoid that someone was trying to kill him. The medical workup in the ED was unremarkable. He was discharged from the ED and since arriving at the facility, he has been verbally aggressive with staff, depressed, throwing food, wandering around, and trying to leave. He does not answer most questions when asked by staff and appears agitated. Psychiatry is consulted for the management of his behavioral and psychological symptoms.
Medical History: Diagnosed with Alzheimer’s Disease 2 years ago (diagnosed based on symptoms and amyloid PET scan), hyperlipidemia (HLD), presbycusis, osteoarthritis (OA)
Social History: Former smoker 1/2 pack per day x 20 years, no substance abuse. ETOH 2-3 drinks on the weekends x 10 years. Married. Previously employed as an accountant
Family History: No history of dementia or mental health disorders. Mother deceased from colon cancer. Father deceased from MI. Son is 31 and healthy.
Medications: Donepezil 5 mg PO HS, Prazosin 1 mg PO HS, Crestor 20mg PO at HS