Crisis Intervention and Treatment Planning for an Agitated Adult/Geriatric Patient with Alzheimer’s Disease

QUESTION

Crisis Intervention and Safety Planning for the Adult/Geriatric Patient

Read the case study located in the reading document.

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 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 work up 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, wanders around, and tries to leave. He does not answer most questions when asked by staff and appears agitated. Psychiatry is consulted for 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 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

Allergies: NKDA

Physical Exam Notes

Constitutional: Appears agitated. Not cooperative. Speech noted is rapid and confused. Inattentive and distracted. Appears slightly hyperactive. Pacing hallways at times.

Head: Normocephalic, atraumatic

Cardiac: RRR, no murmurs noted

Lungs: CTA A/P

Abdomen:  BS x active x 4, soft/non-tender, LBM 2 days ago

Musculoskeletal: Moves all extremities, abnormal/unsteady gait

Neuro: Cranial nerves appear grossly intact but patient not cooperative enough for complete testing. DTRs 1+ symmetric. Disoriented to place and time. Is able to state his name. Unable to complete MMSE.

Vitals: T: 98.8, P 88, R 18, BP 132/78

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.

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 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?

ANSWER

Crisis Intervention and Treatment Planning for an Agitated Adult/Geriatric Patient with Alzheimer’s Disease

Introduction

Crisis intervention and safety planning are crucial components of managing behavioral and psychological symptoms in patients with Alzheimer’s disease. This essay presents a comprehensive SOAP note and treatment plan for Mr. Z, a 68-year-old resident of a long-term care facility, exhibiting agitation, confusion, and verbal aggression. The treatment plan includes prescription details, monitoring considerations, and ethical considerations regarding medication use.

SOAP Note Documentation

Subjective: Mr. Z is a 68-year-old male with a history of Alzheimer’s disease, who presents with agitation, confusion, and verbal aggression. Family reported recent episodes of physical aggression and threats, leading to ED evaluation.

Objective: Upon examination, Mr. Z appeared agitated, with rapid, confused speech, and hyperactivity. His cognitive function was impaired, as evidenced by disorientation to place and time. Neurological assessment revealed cranial nerves intact, but cooperation was limited.

Assessment: Mr. Z exhibits behavioral and psychological symptoms of Alzheimer’s disease, including agitation, confusion, and verbal aggression.

Plan: Initiate crisis intervention and treatment plan to manage symptoms.

Treatment Plan

Medications

Prescription: Lorazepam 0.5 mg PO PRN for agitation and aggression. Administer if patient displays ongoing agitation and distress.
Prescription: Risperidone 0.5 mg PO BID for severe agitation. Start with low dose and monitor for efficacy and side effects.
Provide detailed medication instructions to nursing staff, emphasizing administration only in case of persistent agitation.
Medications should be listed as standing orders, with the requirement to notify the provider before administration.

Doses and Monitoring

Lorazepam: Initial dose 0.5 mg, monitor for sedation and respiratory depression. Repeat dose every 4-6 hours as needed.
Risperidone: Start with 0.5 mg BID, monitor for EPS, drowsiness, and extrapyramidal symptoms.
Monitor vital signs, mental status, and behavior closely after medication administration.
Nursing staff should visually assess patient after medication administration.

Documentation and Continuation

Document patient’s response to medications, including changes in behavior, sedation levels, and potential adverse effects.
Assess patient’s need for ongoing medication based on response to initial doses.
Medications should be continued if they effectively manage agitation and aggression, with regular re-evaluation.

Chemical Restraints Consideration

Medications like lorazepam and risperidone may be considered chemical restraints if used solely to control behavior without a clinical indication.
In Mr. Z’s case, these medications are prescribed to manage severe agitation and aggression that pose a risk to his safety and others, making them medically necessary interventions.

Conclusion

The SOAP note and treatment plan for Mr. Z address his specific symptoms and needs, providing a structured approach to crisis intervention and symptom management. The chosen medications, doses, monitoring, documentation, and ethical considerations collectively aim to ensure patient safety, alleviate distress, and enhance the quality of care provided to Mr. Z in the long-term care facility.