BPSD

45 Collins Street, Melbourne VIC 3000

14/05/2024

Dr Sarah Jenkins,

Re: Arthur Pendelton DOB: 12/08/1941

Thank you for referring Arthur, who was assessed at Oakwood Aged Care Facility on 12/05/2024. A Comprehensive Geriatric Assessment was completed. The matters discussed were:

Issues

1. Severe agitation and physical aggression secondary to Behavioural and Psychological Symptoms of Dementia (BPSD)

Impression: Severe BPSD in the context of moderate-to-severe mixed Alzheimer's and vascular dementia. Brodaty Scale: Tier 5 Behavioural profile: Physical aggression during personal care (hitting, grabbing wrists), verbal agitation, sundowning, and purposeless wandering into other residents' rooms during the late afternoon. Treatment planned: Cease amitriptyline (Endep®) 10 mg PO nocte immediately due to anticholinergic burden. Commence risperidone (Risperdal®) 0.25 mg PO BD, with a plan to review efficacy and extrapyramidal side effects in two weeks. Maximize regular analgesia by increasing paracetamol (Panadol Osteo®) to 1,330 mg PO TID to address potential underlying osteoarthritic pain driving agitation. Non-Pharmacological: Implement a structured afternoon activity schedule, utilize 1:1 redirection during sundowning periods, play personalised music from the 1960s prior to personal care, and ensure two staff members approach from the front with calm verbal cues during hygiene tasks. Relevant Referrals: Referral submitted to Dementia Support Australia (DSA) for on-site behavioural consultancy and care plan formulation.

2. Recurrent mechanical falls and postural instability Arthur has experienced three unwitnessed falls over the past four weeks, likely multifactorial secondary to gait apraxia, spatial disorientation, and polypharmacy. Differential diagnoses include orthostatic hypotension, progression of subcortical vascular disease, and unrecognised osteoarthritic knee pain. Routine bloods including electrolytes, renal function, vitamin B12, folate, and 25-hydroxyvitamin D levels have been requested, alongside a lying and standing blood pressure chart over the next seven days. We will cease amlodipine (Norvasc®) 5 mg PO daily to mitigate mild postural blood pressure drops, and commence colecalciferol (vitamin D3, Ostelin®) 1,000 IU PO daily. A referral has been made to the facility physiotherapist for a mobility review, hip protectors, and sensor mat installation.

3. Bilateral knee osteoarthritis contributing to agitation Arthur demonstrates non-verbal pain cues, including grimacing and rubbing his knees when transferring from sit to stand. Differential diagnoses include crystal arthropathy or meniscal degeneration, though clinical history strongly favours chronic osteoarthritis. Bilateral knee X-rays (weight-bearing where possible) have been ordered via mobile radiology to assess joint space narrowing and exclude occult pathology. Regular modified-release paracetamol (Panadol Osteo®) 1,330 mg PO TID has been charted in place of PRN dosing to ensure baseline pain control. The facility occupational therapist has been asked to review his seating height and bed transfer mechanics.

Past Medical History

Hypertension (1998) Type 2 Diabetes Mellitus, diet-controlled (2005) Bilateral knee osteoarthritis (2012) Benign prostatic hyperplasia (2015) Lacunar stroke, left internal capsule (2019) Mixed Alzheimer's and vascular dementia (2021)

Background and History

Arthur is an 82-year-old gentleman who transitioned into permanent residential care at Oakwood Aged Care Facility six weeks ago following a prolonged hospital admission for delirium superimposed on dementia and carer burnout. Over the past fortnight, facility staff have reported a marked escalation in behavioural disturbances, predominantly occurring between 15:00 and 19:00. Care staff note that Arthur becomes increasingly restless in the afternoons, pacing the corridors and repeatedly attempting to exit the locked memory support unit. When redirected or assisted with incontinence pad changes, he becomes verbally hostile and has struck out at staff on four separate occasions over the past week. His daughter, Margaret, reports that during her visits he frequently packs his clothes into plastic bags, stating, "I need to get to the station before the five o'clock train, Margaret is waiting for me."

Prior to his hospitalisation two months ago, Arthur lived at home with his wife of 58 years, Dorothy. Dorothy struggled to manage his nocturnal wandering and resistance to showering, culminating in an acute presentation to the emergency department when he fell in the bathroom and could not be lifted. Since entering residential care, the loss of familiar surroundings appears to have exacerbated his disorientation. Staff have observed him entering other residents' rooms and rummaging through their wardrobes, which has led to altercations with peers.

During today's consultation, Arthur was pleasant and cooperative in the morning, though he had no insight into his recent aggressive episodes, remarking, "Everyone here is very bossy, they won't let a man go about his business." Margaret expressed significant guilt regarding his placement and distress over the prospect of psychotropic medication, noting, "Dad was always such a gentle, softly spoken accountant; seeing him lash out like this breaks my heart, and I just want him to feel settled and safe." The primary goal of today's review was to identify reversible triggers for his distress, rationalise his medication regimen, and establish a safe, person-centred management plan.

Memory Concerns

Cognitive decline was first noted by his family approximately four years ago, initially manifesting as repetitive questioning, misplacing financial documents, and difficulty managing the household bills. Following a small lacunar infarct in 2019, his cognition showed a stepwise deterioration accompanied by executive dysfunction and slowed processing speed. Over the last 12 months, his short-term recall has deteriorated significantly; he no longer recognises his grandchildren by name and frequently mistakes his daughter for his late sister.

Functional Decline

Arthur has experienced a progressive loss of independence in both instrumental and personal Activities of Daily Living (ADLs). Prior to admission, he had ceased all domestic tasks, meal preparation, and medication management. Currently, he requires full staff assistance for showering, dressing, and grooming due to profound dyspraxia and resistance to care. While he remains able to feed himself finger foods and use a spoon with prompting, he is doubly incontinent and relies on scheduled toileting and continence aids, which frequently acts as a flashpoint for physical aggression.

Living Environment & Family Support

Arthur currently resides in a single room within a secure 20-bed memory support unit. Prior to this, he lived in a single-storey brick home in suburban Melbourne with his wife, Dorothy (80), who suffers from severe rheumatoid arthritis. His daughter, Margaret, lives 15 minutes away from the facility and visits three times a week, remaining heavily involved in his care decisions alongside Dorothy, who visits on weekends with Margaret's assistance.

Systems Review

Weight Change: 3.5 kg weight loss over the past two months secondary to reduced oral intake and constant pacing. Falls: Three unwitnessed falls in the facility corridor over the past month; sustained a superficial skin tear to the right forearm during the most recent fall on 04/05/2024, with no head strike. Mood: Labile; euthymic in the mornings but irritable, anxious, and agitated in the late afternoons. Sleep: Fragmented sleep-wake cycle; wakes 2–3 times overnight calling out for his wife and wandering into the hallway. Pain: Intermittent bilateral knee pain, worse on weight-bearing and transfers, evidenced by facial grimacing. Mobility/Aids Used: Ambulates independently with a 4-wheeled frame (4WF), though frequently forgets to use the aid when agitated. Bowels: Prone to mild constipation; opens bowels every 3–4 days with regular aperients. Bladder: Urinary incontinence; wears pull-up continence pads day and night. Memory: Severe short-term memory impairment, temporal disorientation, and prosopagnosia for extended family. Hearing: Mild bilateral presbycusis; refuses to wear his prescribed hearing aids. Vision: Wears multifocal glasses for reading; history of bilateral cataract extraction in 2017.

Medications on Initial Review

• Donepezil (Aricept®) 10 mg PO mane (for dementia, commenced 2021, good adherence)
• Amlodipine (Norvasc®) 5 mg PO mane (for hypertension)
• Atorvastatin (Lipitor®) 20 mg PO nocte (for secondary stroke prevention)
• Clopidogrel (Plavix®) 75 mg PO mane (for secondary stroke prevention)
• Tamsulosin (Flomaxtra®) 400 mcg PO nocte (for BPH)
• Amitriptyline (Endep®) 10 mg PO nocte (commenced 6 months ago for sleep/neuropathic pain; suspected contributor to confusion and falls)
• Macrogol 3350 (Movicol®) 1 sachet PO daily (for constipation)
• Paracetamol (Panadol®) 1,000 mg PO QID PRN (for knee pain, infrequently administered due to refusal)

Allergies

Penicillin (maculopapular rash)

Suggested Medications Following Consultation

Medication rationalisation is required to reduce anticholinergic burden, mitigate orthostatic hypotension, optimize baseline analgesia, and cautiously manage severe BPSD posing a risk of harm to self and others.

Discontinue: Amitriptyline (Endep®) 10 mg PO nocte; Amlodipine (Norvasc®) 5 mg PO mane. Adjust: Change paracetamol PRN to regular modified-release paracetamol (Panadol Osteo®) 1,330 mg PO TID. Commence: Risperidone (Risperdal®) 0.25 mg PO BD (08:00 and 15:00) for a maximum trial of 4–6 weeks; Colecalciferol (Ostelin®) 1,000 IU PO mane.

Social History

Lives: Secure memory support unit at Oakwood Aged Care Facility. Children: Two adult children; daughter Margaret (54, local) and son David (51, resides in Sydney). Grandchildren: Four grandchildren aged between 16 and 24. Born in: Glasgow, Scotland. Emigrated to Australia in: 1968. ADLs (Personal): Dependent on 1–2 staff for showering, dressing, and toileting; feeds self with supervision. ADLs (Domestic): Fully supported by residential aged care facility. Community Engagement: Previously active in the local bowls club and Probus; now participates sporadically in facility music therapy. Services in place: Permanent residential aged care placement. Driving: Ceased driving in 2020 following stroke and cognitive decline. Falls (last 12 months): Five falls in total (two at home prior to admission, three at the facility). Mobility Aid: 4-wheeled frame (4WF). Education: Completed secondary school and tertiary diploma in accounting. Employment History: Worked as a chartered accountant for a manufacturing firm until retirement at age 65. EPOA/Guardianship: Wife Dorothy and daughter Margaret are joint Enduring Powers of Attorney (Medical and Financial), activated. My Aged Care: Approved for permanent residential care, high level. Smoking/Alcohol: Ex-smoker (ceased 1985, 15 pack-year history); previously drank 1–2 glasses of scotch on weekends, now nil alcohol. Vaccinations: Up to date with seasonal influenza and COVID-19 boosters (last administered 03/2024); received Shingrix®. Family History: Father died of myocardial infarction aged 74; mother had late-onset dementia in her 80s. Exercise: Walks around the unit corridors daily; limited formal exercise tolerance due to knee osteoarthritis.

Physical Examination

Heart Rate: 68 bpm, regular. Blood Pressure: 124/72 mmHg sitting; 108/66 mmHg standing at 1 minute (asymptomatic postural drop). Neuro: Alert, cranial nerves II–XII grossly intact, normal tone in upper and lower limbs, no resting tremor or cogwheeling, reflexes symmetrical, plantar responses flexor bilaterally. Weight: 66.2 kg (BMI 21.6 kg/m²). Gait: Cautious, slightly broad-based gait with reduced stride length and mild stooped posture; unsteady on turning without his 4WF.

Pathology

Recent urinalysis performed on 10/05/2024 was negative for leukocytes, nitrites, and bacteria, excluding an acute urinary tract infection. Fasting bloods from 02/04/2024 demonstrated stable renal function (eGFR 64 mL/min/1.73m²), normal liver function, HbA1c of 6.1%, and a normal thyroid-stimulating hormone (TSH) of 1.8 mIU/L. Repeat electrolyte panels, vitamin D, and bilateral knee X-rays have been ordered today.

Cognitive Assessment

Tool: Mini-Mental State Examination (MMSE). Score: 11/30. Interpretation: Moderate-to-severe cognitive impairment. Comments: Arthur scored 0/5 for temporal orientation, 1/5 for spatial orientation, and 0/3 for delayed recall. He was unable to complete serial sevens or spell WORLD backwards, and demonstrated significant constructional apraxia on pentagon copying.

Summary

Arthur is an 82-year-old male with moderate-to-severe mixed Alzheimer's and vascular dementia presenting with Tier 5 BPSD characterised by afternoon agitation, wandering, and physical aggression during personal care, alongside recurrent falls. Management focuses on deprescribing anticholinergic and antihypertensive agents, optimising regular osteoarthritic pain relief, implementing targeted non-pharmacological behavioural strategies with DSA input, and initiating a low-dose trial of risperidone after obtaining informed proxy consent from his daughter.

Follow-up

I will review Arthur at the facility on 26/05/2024 (in two weeks) to evaluate his response to risperidone, monitor for extrapyramidal side effects, and review his lying and standing blood pressure chart. A formal medication review will be scheduled at six weeks (23/06/2024) to attempt a gradual weaning of risperidone once non-pharmacological strategies and pain management are consolidated.

Kind regards,

Dr Marcus Vance FRACGP, MBBS, DGM Melbourne Mobile Geriatric & GP Services