1. The patient is suffering from advanced Alzheimer's disease (stage 6-7) and is exhibiting behavioral disturbances like wandering, yelling, disrobing, and threatening staff. 2. On evaluation, the patient was pleasant but had terse and incoherent speech. The doctor recommends discontinuing current medications and starting Risperdal to control agitation. 3. The doctor provides strategies for interacting with the patient using short, simple communication and engaging the patient in simple, repetitive activities to reduce restless behaviors like pacing and wandering.

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Mental Health Consultation
Patient Name:
Date(s): Room:
Reasonfor Referral:
Wandering…yelling…disrobing in front of the nursing station…threatening staff…kissing
another resident…placing his hand over another resident’s mouth
Findings and Recommendations:
On interview, he was a tall, smiling, pleasant, cooperative, gentleman with terse, at times,
incoherent and mostly irrelevant speech. There were no apparent signs of delirium.
Despite the many vascular dementia (VaD) risk factors present in his history, clinically he
appears to be suffering from an advanced Alzheimer’s dementia (DAT), stage 6 to stage 7 on the
GDS. At this point in the illness, behavioral disturbances are prominent and speech ability is
severely compromised. Patients become semi-verbal producing no more than six intelligible
words at a time. Eventually, all speech ability is lost. Cognitive decline progresses at a rapid rate
during the final stages of DAT. Neurobehavioral aggressivity is common in advanced
Alzheimer’s patients. Neurobehavioral aggressivity is triggered by trivial events; the aggression
is unplanned, periodic, non-purposeful and impulse driven. Aggressive symptoms include verbal
outbursts, anger and resistance to participation in daily activities. The aggression probably occurs
as a complex psychological response to circumstances and neurochemical changes. Patients
sometimes try to conceal their deficits by adopting an aggressive posture or strike out as a result
of frustrations associated with their cognitive deficits or resist activities that they no longer
comprehend well. When this form of aggression appears, the use of psychoactive medication is
essential in any attempt to manage the behavior. This phenomenon is intensified now because of
the effects of relocation trauma. XXX is an unfamiliar environment for him and the move has
worsened his already severe disorientation. I suspect that the reported “anxiety with panic
attacks” was a misinterpretation of early Alzheimer’s signs.
Pacing, wandering and moving objects are common symptoms in advanced DAT. This is most
likely an attempt to derive sensory stimulation when other sources of stimulation are no longer
available due to severe cognitive loss (i.e. reading, watching television, interacting with others,
etc). In addition, as cognitive capacity declines, patients lose the ability to channel energies
productively. Pacing and wandering becomes a means of discharging excess energy.
1. For now, would continue the Paxil but we may wish to DC it in the near future. His
dementia has probably progressed to a point where depression is unlikely. Generally, as
Alzheimer’s disease progresses, patients lose the psychological and neurophysiologic
complexity required to experience ongoing clinical depression. The past tearfulness was
most likely disinhibition rather than depression.

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2. Would DC the Aricept, the dose is subclinical and his dementia is too far advanced for it
to be helpful.
3. To control his agitation, would DC the Seroquel and start Risperdal 1mg qhs and 0.5mg q
60 prn. We can titrate the routine dose based on prn use.
4. Use the following strategies when interacting with him:
a. Limit the use of questions but when you must ask a question keep to the here and now
and word your questions so they can be answered yes or no or by gesture.
b. Use gesture to communicate when you can.
c. Give one direction or ask one question at a time.
d. Start each conversation by identifying yourself and use short, simple sentences with
familiar words. Smile and use gentile touch (He seems to respond well to this).
e. Provide a sense of security through frequent, brief, reassuring contacts.
f. Avoid presenting him with decisions by using no choice instructions.
g. Try to keep him from engaging in complex tasks, which can lead to failure and
frustration. Substitute simple, failure-free diversions such as folding or sorting.
h. Avoid “why” questions.
5. Provide him with a repetitive activity, which will allow for the discharge excess restless
energy in ways other than wandering and pacing. He was an Engineer, perhaps something
mechanical but very simple.
6. To reduce the effects of relocation trauma, ask family members to bring in objects, which
are of sentimental significance to him and place them about his room and to visit him at
regular and predicable intervals.
___________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist