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Neurocognitive Case Study Workshop Paper – Part 2

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Neurocognitive Case Study Workshop Paper – Part 2

Delirium in elderly patients, such as Margaret Johnson, should be addressed through a combination of pharmacological and non-pharmacological management strategies. In this case, treatment approaches will be compared and tailored in the context of Alzheimer’s disease and Lewy body dementia to ensure optimal care and outcomes: Neurocognitive Case Study Workshop Paper – Part 2.

Evidence-Based-Non-Pharmacological Treatment for Delirium

Non-pharmacological interventions are the initial management of delirium, addressing its causes, correcting the environment, and stabilizing cognitive function while avoiding proportionate aggravation with any drug interventions.

Reorientation and Cognitive Stimulation

One of the most effective interventions is reorientation and cognitive stimulation, according to Fatima et al. (2025). Delirium is a common condition in patients, especially in non-psychiatric settings, and is characterized by confusion and particularly disturbance in the perception of time, place or state. To reduce the risk of this, the healthcare provider should provide frequent verbal cues, keep clocks and calendars within the patient’s reach, and surround the patient with objects familiar to them. Studies indicate that engaging patients in structured cognitive activities, such as reading, conversation, and puzzles, enhances cognitive function and decreases delirium symptoms (Garrido et al., 2023).

Environmental Modification

Another useful strategy is environmental manipulation, in which findings showed that minimizing stimulation could reduce confusion and agitated status in a patient with delirium (Austin et al., 2023). A quiet, well-lit room with minimal distractions reduces overstimulation, which is a common exacerbating factor for delirium. Additionally, maintaining consistent daily routines and limiting room changes in assisted living settings helps provide continuity and stability for patients. Proper sleep hygiene, such as reducing nighttime disturbances and controlling light exposure, is also essential in preserving the circadian rhythm and preventing nocturnal confusion (Lee et al., 2023).

Hydration and Nutritional Support

Hydration and nutritional support are critical components of delirium management, as studies show that dehydration and malnutrition are among the leading precipitating factors for delirium in elderly populations (Dahal & Bista, 2023). Ensuring adequate fluid intake can prevent electrolyte imbalances and reduce cognitive impairment. In patients with underlying conditions such as diabetes, as seen in Margaret’s case, monitoring blood glucose levels is essential, as fluctuations in glucose levels have been associated with acute cognitive disturbances. Encouraging a nutrient-rich diet with appropriate macronutrients supports neurological function and recovery.

Family Involvement and Emotional Support

The patient’s family and the provision of emotional support are key components of the comprehensive approach to the treatment of the problem. According to the literature, family involvement in the care of patients with delirium enhances the clients’ well-being by offering comfort and orientation assistance (Dahal & Bista, 2023). Frequent visits also help with reorientation, besides reducing distress and anxiety among the patients. Furthermore, the use of prayer or topics of faith can be valuable for a patient’s comfort in their psychological or social sense, especially in patients like Margaret, who is Catholic.

Pharmacological Treatment for Delirium

Pharmacologic management of delirium is limited to cases of persistent agitated or distressed behaviour, and the process should be based on available evidence and principles of geriatric pharmacotherapy.

Antipsychotic Medications

Antipsychotics are the primary medication treatment option for the management of agitated behaviours or psychotic symptoms in delirious patients. An example of the first generation is haloperidol (Haldol), which will be at 0.5 – 1 mg PO/IM PRN, with little anticholinergic side effects and less sedation (Wilson et al., 2020). However, it should be used with some precautions due to its extrapyramidal effects.

A different preferable choice is Risperidone (Risperdal) 0.25-0.5 mg PO daily due to its better side effect profile, particularly with regard to extrapyramidal symptoms (EPS) (Stahl, 2021). Regarding Parkinsonian features that indicate Delirium, quetiapine 12.5-25 mg oral at night should be preferred over other atypical antipsychotics because of their relatively low levels of dopaminergic antagonism in patients with Parkinson’s disease (Chokhawala & Stevens, 2023).

Benzodiazepines (Limited Use for Withdrawal-Related Delirium)

Benzodiazepines are not suggested for the treatment of delirium because they can cause further confusion and increase the risk of falls in elderly patients. However, for patients experiencing alcohol or benzodiazepine withdrawal delirium, Ativan 0.5 mg PO/IV PRN can be considered safer as this has a shorter half-life and lesser accumulation in elderly patients (Chokhawala & Stevens, 2023). The major drawback of opioids is oversedation and respiratory depression; therefore, monitoring is critical.

Acetylcholinesterase Inhibitors for Cognitive Support

If there is a suspicion of underlying dementia, long-term cognitive support with acetylcholinesterase inhibitors such as Donepezil (Aricept) 5 mg PO daily is recommended (Garrido et al., 2023). Although these medications are not typically used for treating delirium, they could be useful as they increase cholinergic activity, improving cognitive function.

Supportive Medications for Symptom Management

The application of atypical neuroleptic drugs makes it possible to treat symptoms of delirium without many side effects from the neuroleptic syndrome. In this case, melatonin 3 mg PO at bedtime helps in encouraging sleep but does not worsen confusion or induce sedation (Austin et al., 2023). Secondly, Acetaminophen is preferable to opioids for managing pain because opioids cause the deterioration of delirium by decreasing CNS activity.

Comparison with Differential Diagnoses

Understanding the differences in treatment between delirium, Alzheimer’s Disease (AD), and Lewy Body Dementia (LBD) is critical for optimizing patient care. The following table summarizes the pharmacological and non-pharmacological management of each of the conditions as per the current evidence-based guidelines.

Treatment Approach Delirium (Primary Diagnosis) Alzheimer’s Disease (AD) Lewy Body Dementia (LBD)
Pharmacological Treatment Antipsychotics (haloperidol, risperidone) for severe agitation. Benzodiazepines only if withdrawal-related. Short-term use only (Garrido et al., 2023). Acetylcholinesterase inhibitors (donepezil, rivastigmine) and NMDA receptor antagonists (memantine) to slow cognitive decline. Antipsychotics are used cautiously if necessary. Acetylcholinesterase inhibitors (donepezil, rivastigmine) to improve cognition. Antipsychotics are generally avoided due to neuroleptic sensitivity; if needed, quetiapine or clozapine are preferred.
Non-Pharmacological Treatment Reorientation strategies, environmental modifications, hydration, and sleep regulation to stabilize cognition and reduce agitation. Cognitive stimulation therapy, structured routines, and caregiver education to slow disease progression and enhance daily functioning. Fall prevention, visual aids, physical therapy, and autonomic dysfunction management to reduce risks associated with motor and cognitive impairment.

 Key Differences and Considerations

Delirium requires rapid intervention with antipsychotics for severe agitation while addressing underlying medical conditions such as infection, dehydration, or medication side effects. In contrast, Alzheimer’s disease (AD) treatment prioritizes long-term cognitive support, utilizing cholinesterase inhibitors and behavioural therapies, with limited antipsychotic use for behavioural disturbances. Consistently, Lewy Body Dementia (LBD) is very sensitive to the use of antipsychotics due to the deleterious effect of dopamine-blocking medications on motor function (Garrido et al., 2023). Acetylcholinesterase inhibitors are the initial treatments of choice in patients with LBD.

Special Considerations in Prescribing for Older Adults

Prescribing medications for older adults requires careful consideration due to age-related physiological changes, increased sensitivity to medications, and the potential for drug interactions. A patient-centered approach ensures that treatments are safe, effective, and aligned with the patient’s health goals.

Increased Sensitivity to Medications

Elderly adults have decreased liver and renal function, and this has an impact on drug half-life, hence the accumulation of drugs in the body (Chokhawala & Stevens, 2023). This implies that administering a medication that is well tolerated in younger patients may cause some side effects in elderly patients. This is known as the concept of ‘start low, go slow’—the technique of exposing the patients to medication at the smallest possible dose and increasing the doses gradually to reduce any side effects while maximizing therapeutic gains (Fatima et al., 2025).

Polypharmacy and Drug Interactions

Polypharmacy is prevalent in the elderly, and it results in a relatively higher danger of adverse drug effects and interaction risks. Regarding Margaret Johnson’s current medications, potential drug-drug interactions with new medications such as metformin, lisinopril, and vitamin D should be checked. Overall, antipsychotics and cholinesterase inhibitors used in neurocognitive disorders are followed closely to avoid cardiovascular issues, over-sedation, or altered metabolism (Garrido et al., 2023). A complete medication reconciliation decreases the number of medications taken through polypharmacy to avoid the side effects of such.

Fall Risk and Sedation

Specific drugs that escalate the risk of falls, fractures, and cognitive decline include benzodiazepine and sedating antipsychotic drugs such as olanzapine, among others (Garrido et al., 2023). Taking falls into consideration is an important step in medication management since falls are one of the biggest concerns for the elderly population. No sedative medications should be given unless there is no other option in the interest of the patient’s safety. These warrants changing the doses or finding other medicines to avoid any incidences that may lead to harm while being sedated.

Cardiovascular Risks

Cardiac side effects are more common in older patients and include QT prolongation, which increases the risk of serious arrhythmias. Haloperidol and risperidone are some of the drugs that have been linked to QT interval prolongation; therefore, patients who are at risk should undergo cardiac monitoring. This is because while addressing the symptoms may bring comfort to the patient, it increases cardiovascular problems, especially in patients who have pre-existing heart conditions.

References

Austin, C. A., Palanca, B. J. A., Smith, K., Chapin, B., Lin, S.-Y., Khan, S., Lindroth, H., Oldham, M., & Maya, K. (2023). American Delirium Society 2022 Year in Review: Highlighting the Year’s Most Impactful Delirium Research. Delirium Communications, 78(98). https://doi.org/10.56392/001c.73356

Chokhawala, K., & Stevens, L. (2023, February 26). Antipsychotic medications. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519503/

Dahal, R., & Bista, S. (2023, February 20). Strategies to reduce polypharmacy in the elderly. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK574550/

Fatima, E., Hill, I., Dover, N., & Faisal, H. (2025). Exploring Cognitive Stimulation as a Therapy for the Prevention of Delirium in a Hospital Setting: A Narrative Review. Behavioral Sciences, 15(2), 186–186. https://doi.org/10.3390/bs15020186

Garrido, M., Álvarez, E., Salech, F., Rojas, V., Jara, N., José Ignacio Farías, Ponce, D., & Tobar, E. (2023). Software-guided (PREVEDEL) cognitive stimulation to prevent delirium in hospitalised older adults: study protocol. BMC Geriatrics, 23(1). https://doi.org/10.1186/s12877-023-04189-2

Lee, H.-J., Jung, Y.-J., Choi, N.-J., & Hong, S.-K. (2023). The effects of environmental interventions for delirium in critically ill surgical patients. Acute and Critical Care, 38(4), 479–487. https://doi.org/10.4266/acc.2023.00990

Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press

Wilson, J. E., Mart, M. F., Cunningham, C., Shehabi, Y., Girard, T. D., MacLullich, A. M. J., Slooter, A. J. C., & Ely, E. W. (2020). Delirium. Nature Reviews Disease Primers, 6(1), 1–26. https://doi.org/10.1038/s41572-020-00223-4

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Question

Part Two : Pharmacological & Non-Pharmacological Treatment of Neurocognitive Disorders.

Purpose
This assignment allows students to evaluate the therapeutic interventions for neurocognitive disorders. The student will be assigned one of the available case studies from this assignment at the beginning of the course. The student determined their assigned client’s primary and differential diagnoses in part one of this assignment. Based on the client’s diagnosis, the student will explore the therapeutic treatment recommendations for their client.

The student will contrast these recommendations for the primary diagnoses with the evidence-based recommendations for the differential diagnoses. The student will explain specific considerations in the pharmacological intervention of their older adult client. As a reminder the paper is broken down into sections each week, ending with a presentation in week three of the course.

Neurocognitive Case Study Workshop Paper – Part 2

Neurocognitive Case Study Workshop Paper – Part 2

Part Two – Module Two

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