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

question 1011

Multiple Choice

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?

• A)Increase antipsychotics for adequate control of behavioral symptoms
• B)Initiate levodopa and carbidopa for the parkinsonian symptoms
• C)Obtain an MRI of the brain to evaluate for Lewy body dementia
• D)Prescribe empiric antibiotics to treat delirium due to urinary tract infection
• E)Recommend behavioral interventions and discontinue antipsychotics