An 85-year-old man is evaluated at a nursing home due to intermittent agitation. The patient has dementia and has been residing in the facility for several years. He can communicate his needs but does not recognize his caregivers and requires assistance with all activities of daily living. According to the staff, the patient has had intermittent agitation and aggression; these have become somewhat more frequent over time. The patient is unable to provide meaningful history, but there is no report of fever, cough, abdominal pain, urinary symptoms, or change in appetite. Records indicate a history of hypertension but no cerebrovascular accidents or Parkinson disease. His only medications are olanzapine and haloperidol as needed for agitation. Temperature is 37 C (98.6 F), blood pressure is 130/70 mm Hg, and pulse is 78/min. The patient is comfortable but confused and oriented to self only. Lungs are clear to auscultation and heart sounds are normal. The abdomen is soft and nontender with normoactive bowel sounds. Neurological examination reveals mild resting hand tremors and rigidity of both arms. There is no extremity edema or rash. Which of the following is the most appropriate next step in management of this patient?

Question

An 85-year-old man is evaluated at a nursing home due to intermittent agitation.  The patient has dementia and has been residing in the facility for several years.  He can communicate his needs but does not recognize his caregivers and requires assistance with all activities of daily living.  According to the staff, the patient has had intermittent agitation and aggression; these have become somewhat more frequent over time.  The patient is unable to provide meaningful history, but there is no report of fever, cough, abdominal pain, urinary symptoms, or change in appetite.  Records indicate a history of hypertension but no cerebrovascular accidents or Parkinson disease.  His only medications are olanzapine and haloperidol as needed for agitation.  Temperature is 37 C (98.6 F), blood pressure is 130/70 mm Hg, and pulse is 78/min.  The patient is comfortable but confused and oriented to self only.  Lungs are clear to auscultation and heart sounds are normal.  The abdomen is soft and nontender with normoactive bowel sounds.  Neurological examination reveals mild resting hand tremors and rigidity of both arms.  There is no extremity edema or rash.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This elderly man with dementia and intermittent agitation, for which he is on multiple antipsychotics, now has resting tremors and upper extremity rigidity, suggestive of drug-induced parkinsonism due to antipsychotics (haloperidol, olanzapine). In patients with dementia, neuropsychiatric symptoms (eg, agitation, aggression, hallucinations) are common and may become more pronounced, particularly at night (sundowning), as the disease progresses. Treatment options include behavioral interventions (eg, activities, music therapy, communication skills training for caregivers), antidementia drugs, and antidepressants. Although antipsychotics are sometimes used (particularly in severe or refractory cases), they are associated with increased mortality and multiple side effects, including extrapyramidal symptoms (eg, secondary parkinsonism, akathisia, dystonias). Secondary parkinsonism causes cogwheel rigidity, "pill-rolling" resting tremors, masked facies, shuffling gait, and bradykinesia, many of which are seen in this patient. Because this patient has significant side effects and only intermittent agitation (likely due to dementia progression), his antipsychotic regimen should be stopped, and behavior interventions to treat his agitation should be implemented. Antipsychotics are typically reserved for patients in whom the safety of the patient or caretaker is threatened; their use should be minimized. (Choice A) Increasing this patient's antipsychotic regimen will likely worsen his secondary parkinsonism. In patients with suspected primary Parkinson disease, haloperidol should be avoided as it can exacerbate symptoms. (Choice B) Levodopa and carbidopa are used to treat motor disturbances in primary Parkinson disease. However, Parkinson disease begins with motor symptoms, and patients develop dementia late in the disease, unlike this patient who developed parkinsonian features years after dementia. Levodopa and carbidopa are not indicated in secondary parkinsonism caused by antipsychotics. (Choice C) Lewy body dementia causes parkinsonian symptoms, dementia, and increased sensitivity to neuroleptic medications (eg, exacerbation of parkinsonism, confusion with neuroleptic agents). However, these patients develop visual hallucinations, autonomic dysfunction (eg, orthostatic hypotension, urinary incontinence), and fluctuations in levels of cognition (eg, episodes of "blanking out," bizarre behavior, excessive somnolence), which are not noted in this patient. Haloperidol is contraindicated in patients with Lewy body dementia due to neuroleptic sensitivity. (Choice D) In patients who are elderly or have dementia, urinary tract infections can cause worsening agitation with minimal urinary symptoms. However, they would not be expected to cause parkinsonian symptoms, and it is unlikely that an untreated urinary tract infection would last 2 months without the patient experiencing marked clinical deterioration. Educational objective: Neuropsychiatric symptoms are common among patients with dementia; treatment includes behavioral interventions, antidementia drugs, and antidepressants. Antipsychotics are sometimes used but are associated with increased mortality and multiple side effects, including extrapyramidal symptoms. If possible, antipsychotics should be discontinued in patients who develop side effects.

An 85-Year-Old Man Is Evaluated at a Nursing Home Due