How I Treat: What is the home caregiver to do? Case Presentation

The patient is an 85-year-old man living at home with his wife. He has been living with Alzheimer disease for the past 6 years and is currently in a moderate stage. He also has severe osteoarthritis in both knees and is frequently unable to ambulate without significant pain. Prior to his illness, he was a very active and sociable man, but in the past year as his cognitive impairment has declined he has become impatient and belligerent at times. Specifically, he engages in some of the following disruptive behaviors: anger, screaming and threats towards his wife, paranoid accusations of being poisoned, and resistance to any help coming in the house.

He takes medications for hyperlipidemia, gastrointestinal reflux and pain, including rosuvastatin, famotidine, ibuprofen, and tramadol, but he has not been prescribed anything routinely for his behaviors. Instead, his wife has been giving him several over-the-counter sleeping pills to calm him and make him sleepy. She is exhausted by having to care for him alone since he has acted out towards any aide she tried to bring into the house. After one particularly bad outburst incident, she brought him to his neurologist who increased the tramadol dose and added memantine to his acetylcholinesterase inhibitor donepezil. However, his agitated behaviors continued without any improvement. As a result, his wife is wondering whether she should put him in a locked memory care unit.