One of my patients with memory problems (F00.02 dementia in Alzheimer's disease, early onset, severe) has finally ground his wife down so much that he's been placed in emergency respite care.
She's been managing him, essentially single handedly, for an age.
He's got a lot of Parkinsonian motor symptoms and a changeable presentation and misperceptions suggesting visual hallucinations so I think he may well have Lewy Body dementia but he'd not tolerate DAT Scanning and is too advanced for detailed neuropsych evaluation.
He has behavioural and psychological symptoms of dementia (BPSD). He wanders, a lot. In our day centre, throughout the day he'd spend 6 hours walking and only half an hour sat down. He bangs walls when he's frustrated. Left alone, he never troubles other people.
In the care home, he's wandering at night. Staff didn't like that so tried to force him in to bed. He didn't like that. He's now labelled as "aggressive" and staff want more medication. Through the day he wanted to walk outside. He didn't want to wait 'til the afternoon when the late shift would open the doors and let him walk in the enclosed garden, so he walked around inside. He's now labelled as "restless."
It's an EMI Nursing Home so has qualified mental health nurses and experienced care staff, but to support them my nursing colleagues or I have been visiting 3 days a week.
He's on galantamine (to manage BPSD rather than improve cognition, now) and lorazepam to de-escalate arousal and distress. The care home sought haloperidol 3 times this week from his GP. His GP said no.
His GP 'phoned me up. We talked through what was going on. Because this was urgent respite placement, the nursing home is outside my patch, thus the GP looking after the home isn't someone I know or have ever had contact with before. But I could have kissed her. She's seen my patient, she thought maybe he had Lewy Body dementia and haloperidol would be A Bad Thing. She saw that the wife had managed the man alone, so why did a specialist care home with oodles of staff need medication when she did not? She saw that lorazepam had worked so a touch more may well help him settle in a disorienting environment. She saw him as active but no risk to others, not warranting sedating. She'd spotted relevant physical comorbidity that I'd spent half an hour sorting out last time, she generated sensible drug strategies to manage this over the next week.
The patient's in the right sort of care home, having rich input from specialist dementia care nurses and myself, is on appropriate medication and has a GP coordinating mental health and physical health care, and advocating for care home staff to use behavioural rather than pharmacological strategies to manage BPSD.
Some days, everything's just peachy! :-)