'How I Treat': Managing Anxiety From Underlying Agitation Due to Alzheimer Disease Case Presentation

Patient Information:

• Name: Mr. John Doe (pseudonym for confidentiality)
• Age: 80 years
• Sex: Male
• Referral Source: Family Senior Care Advisor
• Presenting Concern: Establish psychiatric care for agitation associated with Alzheimer disease

Background:

Mr John Doe is an 80-year-old male who presents with his daughter and wife to an outpatient psychiatric clinic for evaluation and management of agitation linked to his Alzheimer disease. He has a known history of Alzheimer dementia, which has led to a gradual decline in cognitive function. The family seeks to address concerns regarding irritability and anxiety, especially in relation to his memory difficulties.

Mr Doe is a retired military veteran with a history of neurotoxin exposure during his service. His medical history includes hypertension (HTN) and a previous myocardial infarction (MI). He has mild anxiety symptoms (current GAD score -5), though depression is not significantly present at this time.

Presenting Issues:

Mr Doe’s agitation has become noticeable, particularly in interactions with his wife, when asked questions he does not know the answers to due to his memory limitations. This has led to increased irritability and frustration. The family reports that these emotional outbursts are typically brief but occur regularly. The patient’s anxiety is also exacerbated in situations where he feels he cannot control or manage his environment.

Despite these challenges, Mr Doe enjoys socializing with friends, playing games, and watching comedy shows, activities that help him maintain a sense of connection and enjoyment. He walks his dog nightly, maintaining a sense of routine and physical activity. He does not drive.

Medical and Psychiatric History:

• Alzheimer disease (AD): Diagnosed several years ago; cognitive decline with increasing memory deficits, particularly short-term memory.
• Hypertension (HTN): Managed with medication.
• Myocardial Infarction (MI): Past history, managed with lifestyle modifications and medication.
• Neurotoxin Exposure: Military service resulted in potential exposure to neurotoxic substances, though no specific diagnosis or detailed impact is documented.
• Mental Health: Mild generalized anxiety symptoms; no significant depression symptoms reported.
• Medications: Aspirin 81mg, atorvastatin, lisinopril, tamsulosin, and magnesium supplement
• Prior medication history: Tapered off memantine due to side effects.

Assessment of Agitation:

In Alzheimer disease, agitation is a common neuropsychiatric symptom that can manifest as irritability, aggression, anxiety, or emotional lability.

Agitation often arises due to:

• Memory limitations (e.g., forgetfulness, confusion) leading to frustration.
• Loss of control or autonomy in daily activities, including interaction with loved ones
• Environmental factors such as changes in routine or unfamiliar situations, which can trigger stress responses.

In this case, Mr Doe’s agitation seems primarily linked to his cognitive decline, specifically memory loss and difficulties with tasks he previously found familiar or easy. His anxiety is likely a reflection of his awareness of these limitations, particularly when prompted by questions or reminders from his wife.

The most appropriate primary treatment approach would likely be option 4: Focus on non-pharmacological strategies such as behavioral therapy, caregiver training, and structured routine.

While medication may be necessary (eg, cholinesterase inhibitors for cognitive decline or SSRIs for anxiety), non-pharmacological interventions play a crucial role in managing agitation, improving the quality of life, and reducing the need for medications like antipsychotics, which carry potential risks in elderly patients with Alzheimer dementia.

A structured routine, caregiver training, and behavioral therapies like CBT or validation therapy can help address agitation in a holistic manner.

Taylor Crews, APRN, PMHNP-BC, is a psychiatric nurse practitioner with over a decade of experience. Currently, Crews is a provider with Sweetgrass Psychiatry, practicing medication management across the lifespan and serving as the ketamine clinical specialist. For 5 years, she served long-term care facilities as a psychiatric NP consultant specializing in geriatric mental health. Crews holds a Bachelor of Science in Nursing from Carroll University and a Master of Science in Nursing from the University of South Alabama. Her expertise spans geriatric care, crisis intervention, advanced medication management, and esketamine treatment for treatment-resistant depression.

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