A 58-year-old woman comes to the office for an annual health examination. She has a history of hypothyroidism, hypercholesterolemia, and depression. Medications include levothyroxine, simvastatin, and escitalopram. The patient reports feeling "tired and worn out" due to difficulty falling asleep and also awakening several times a night over the past several months. She reports no change in appetite, bowel habits, interest in activities, or concentration. The patient limits her caffeine intake to mornings and does not drink alcohol. She quit her job last year in order to care full-time for her mother, who has Alzheimer disease and lives with her. The patient says, "It's been difficult to see my mother decline, and I worry because she is increasingly confused and wanders at night. I feel badly, because I get irritable when I am tired and lose patience with her. I would like to keep Mom at home as long as possible, but it is difficult."
Vital signs and physical examination are unremarkable. TSH is within normal limits.
Which of the following is the most appropriate intervention for this patient?

Question

A 58-year-old woman comes to the office for an annual health examination.  She has a history of hypothyroidism, hypercholesterolemia, and depression.  Medications include levothyroxine, simvastatin, and escitalopram.  The patient reports feeling "tired and worn out" due to difficulty falling asleep and also awakening several times a night over the past several months.  She reports no change in appetite, bowel habits, interest in activities, or concentration.  The patient limits her caffeine intake to mornings and does not drink alcohol.  She quit her job last year in order to care full-time for her mother, who has Alzheimer disease and lives with her.  The patient says, "It's been difficult to see my mother decline, and I worry because she is increasingly confused and wanders at night.  I feel badly, because I get irritable when I am tired and lose patience with her.  I would like to keep Mom at home as long as possible, but it is difficult."
Vital signs and physical examination are unremarkable.  TSH is within normal limits.
Which of the following is the most appropriate intervention for this patient?

Quizplus · Accepted Answer

This patient's sleep disturbance and irritability are suggestive of caregiver distress. The burden of caring for dementia patients at home is considerable and increases as cognitive function declines and behavioral symptoms worsen (eg, wandering, agitation, aggression, psychosis). Signs of caregiver distress include sleep disturbance, depression, irritability, and anxiety as well as negative effects on physical health. Without intervention, the situation can progress to caregiver burnout, mental and physical illness, and increased likelihood of early nursing home placement for those with dementia. Early recognition of caregiver burden and providing assistance with obtaining support services can reduce distress and prevent burnout. Respite care services include in-home care services, adult day centers, and overnight care, which allow caregivers to take a break or vacation. Other helpful interventions include caregiver support groups, as well as comprehensive support programs that can assist caregivers in assessing the needs of the patient with dementia and the appropriate level of care as the disease progresses. (Choices A and B) Although education about the course of Alzheimer dementia and praising the patient's efforts are important, these interventions are not a substitute for relieving her burden by providing respite services. (Choices C and E) Caregivers are at increased risk for depression, and the physician should be vigilant for signs of depressive relapse in this patient. However, this patient is not showing other symptoms of depression. Her poor sleep is likely a result of caregiver stress and the need to monitor her mother's nighttime wandering. Alleviating her caregiving burden rather than increasing her antidepressant medication or adding a sleep medication would be a more appropriate first step. Educational objective: Caregiver distress can result in poor physical health and sleep and mood disturbances, as well as early nursing home placement for relatives with dementia. Support services (eg, respite care, support groups and programs) can help reduce caregiver burden. __________ References: Prevalence and predictors of burden in caregivers of people with dementia. (http://www.ncbi.nlm.nih.gov/pubmed/24012226) Caregiver burden: a clinical review. (http://www.ncbi.nlm.nih.gov/pubmed/24618967) Formal support for informal caregivers to older persons with dementia through the course of the disease: an exploratory, cross-sectional study. (http://www.ncbi.nlm.nih.gov/pubmed/26832354)

A 58-Year-Old Woman Comes to the Office for an Annual