What case‑management recommendations are appropriate for a 65‑year‑old male recently admitted after months of medication non‑adherence and cognitive decline, who has a traumatic subdural hematoma, anemia, vitamin D deficiency, hypertension, major depressive disorder, anxiety, insomnia, gastro‑esophageal reflux disease, a healing facial fracture, established dementia, and is taking levetiracetam, amlodipine, atorvastatin, vitamin D, famotidine, latanoprost, melatonin, mirtazapine, sertraline, and terbinafine?

Case Management Recommendations for a 65-Year-Old Male with Dementia, Medication Non-Adherence, and Multiple Comorbidities

This patient requires immediate implementation of a structured medication management system with caregiver oversight, systematic investigation of reversible causes of cognitive decline (particularly infection and metabolic disturbances), and optimization of his current medication regimen before considering any additional psychotropic medications. 1

Immediate Priority: Address Medication Non-Adherence and Safety

Establish supervised medication administration immediately – this patient's months-long medication non-adherence, including seizure medications, poses imminent risk of seizure recurrence and further cognitive decompensation. 2, 3

• Implement a structured medication management system with written documentation, simplified regimens, and direct facility staff oversight of all medication administration. 2
• Compile a complete medication list by having staff bring all medication bottles to verify what the patient is actually taking versus what is prescribed, and assess for drug interactions and anticholinergic effects. 2, 1
• Partner with the facility pharmacist to optimize medication management, determine appropriate dosages, identify potential interactions, and eliminate unnecessary or dangerous medications. 2

Critical Medical Workup: Rule Out Reversible Causes

Before attributing symptoms solely to dementia, systematically investigate treatable medical contributors that commonly drive cognitive decline and behavioral symptoms in elderly patients. 1

Infection Screening

• Check for urinary tract infection and pneumonia – these are major triggers of cognitive decompensation in dementia patients who cannot communicate discomfort. 4, 5
• Obtain urinalysis, urine culture, chest X-ray if clinically indicated based on vital signs and examination findings. 4

Metabolic Assessment

• Evaluate for dehydration, electrolyte imbalances, and hyperglycemia – all can worsen confusion and cognitive function. 4, 1
• Check vitamin B12 and thyroid function – reversible causes of cognitive impairment that should be screened in all dementia patients. 1
• Assess for constipation and urinary retention – both significantly contribute to agitation and confusion in dementia patients. 5, 1

Pain Assessment

• Systematically evaluate for pain using observation-based tools since the patient may not reliably report discomfort – untreated pain is a major contributor to behavioral disturbances. 5, 1

Neuroimaging Considerations

• Given the history of traumatic subdural hemorrhage and facial fracture, confirm resolution or stability with repeat imaging if not recently performed, as chronic subdural hematoma can present with cognitive decline and neuropsychiatric symptoms. 6, 4

Medication Review and Optimization

Conduct a comprehensive medication review to identify drugs that may be worsening cognitive function or increasing fall risk. 1, 2

Identify and Discontinue Problematic Medications

• Screen for anticholinergic medications (diphenhydramine, hydroxyzine, oxybutynin) that worsen confusion and agitation – none are currently listed but verify with complete medication reconciliation. 5, 2
• Review all medications for potential cognitive side effects and drug-drug interactions, particularly given polypharmacy. 1

Optimize Current Regimen

• Ensure levetiracetam 750 mg dosing is appropriate for his renal function (check creatinine clearance) and seizure control – this is critical given his history of medication non-adherence and seizure risk. 4
• Simplify the medication schedule by consolidating dosing times where possible to reduce complexity and improve adherence. 2, 7
• Consider once-daily formulations where therapeutically appropriate to facilitate adherence. 7

Address Vitamin D Deficiency

• Increase vitamin D supplementation from 1000 units to at least 2000 units daily, as deficiency is common in dementia patients and adequate supplementation should be ensured. 1

Nutritional Assessment and Management

Address the discrepancy between patient report ("has not eaten since admission") and staff observation (patient has been eating) – this indicates significant cognitive impairment affecting insight and memory. 1

• Conduct a detailed nutritional assessment using simple questions like "What do you eat on a normal day?" and document actual intake. 1
• Perform oral cavity examination to check for abnormalities in teeth, gums, tongue, and oral mucosa that may impair eating. 1
• Screen for swallowing difficulties using the Eating Assessment Tool-10 scale; refer to speech therapy if score ≥3. 1
• Assess for sarcopenia following European Working Group on Sarcopenia in Older People 2 guidelines, given his anorexia and dementia. 1
• Ensure adequate protein and calorie intake – if consuming <1500 kcal/day, recommend daily multivitamin supplementation. 1
• Monitor hydration status – ensure daily fluid intake of 2.0 L for men, as individuals with dementia often forget to drink. 1

Cognitive and Functional Assessment

Document baseline cognitive function using standardized screening to guide treatment decisions and monitor for further decline. 1

• Administer Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) to quantify cognitive impairment. 1
• Assess executive function and medication management capacity – this patient's lack of insight into his diagnoses and denial of need for medications suggests impaired executive function. 3, 1
• Evaluate decision-making capacity regarding medical care and determine if surrogate decision-maker involvement is needed. 1

Behavioral and Psychiatric Management

The patient's denial of medical/psychiatric diagnoses and lack of insight requires careful management without adding unnecessary psychotropic medications at this time. 5, 2

Non-Pharmacological Interventions First

• Implement environmental modifications: ensure adequate lighting, reduce excessive noise, provide predictable daily routines. 5, 1
• Use effective communication strategies: calm tones, simple one-step commands, allow adequate time for processing information. 5, 1
• Educate facility staff that behaviors are symptoms of dementia, not intentional actions. 5

Current Psychiatric Medications

• Continue sertraline 100 mg for major depressive disorder – this is appropriate first-line treatment. 5
• Continue mirtazapine 45 mg for depression and appetite stimulation – appropriate given his anorexia. 5
• Continue melatonin 3 mg for insomnia – this is a safer alternative to benzodiazepines in elderly patients. 5
• Do NOT add antipsychotics unless the patient becomes severely agitated, distressed, or poses substantial harm to self or others after behavioral interventions have failed. 5, 2

Falls Risk Assessment and Prevention

Given his history of traumatic subdural hemorrhage and facial fracture, falls prevention is critical. 1

• Conduct comprehensive falls risk assessment including gait evaluation, environmental hazards, and medication review. 1
• Install safety equipment: grab bars, adequate lighting, remove tripping hazards. 5
• Monitor for orthostatic hypotension given amlodipine use – BP 136/88 is acceptable but assess for postural changes. 1
• Avoid benzodiazepines and minimize sedating medications that increase fall risk. 5, 1

Monitoring and Follow-Up

Establish a structured monitoring plan with clear endpoints and reassessment intervals. 2, 1

• Schedule medication reviews every 3-6 months to evaluate ongoing necessity and identify opportunities for deprescribing. 2
• Monitor for medication side effects including extrapyramidal symptoms (from any future antipsychotic use), falls, sedation, and metabolic changes. 5, 2
• Reassess cognitive function with any significant change in clinical status or increased difficulty with self-care. 1
• Monitor seizure control closely given his history of non-adherence to levetiracetam. 4
• Track nutritional status and weight monthly to ensure adequate intake. 1

Caregiver and Facility Staff Education

Provide targeted education to facility staff about this patient's specific needs and high-risk medications. 2

• Educate staff about seizure precautions and what to do if a seizure occurs, given his history of medication non-adherence. 4
• Teach recognition of medication side effects that warrant immediate medical attention, including sudden confusion, falls, or difficulty breathing. 2
• Provide education on non-pharmacological interventions for behavioral symptoms before requesting medication adjustments. 5, 2
• Explain the importance of consistent medication administration and documentation of any missed doses. 2, 3

Multidisciplinary Team Coordination

Engage a multidisciplinary team to address this patient's complex needs. 1, 2

• Involve physical therapy to assess mobility, develop fall prevention strategies, and maintain functional capacity. 5
• Engage occupational therapy to evaluate activities of daily living and recommend adaptive equipment. 1
• Consider dietitian consultation to ensure nutritional recommendations are tailored to his needs. 1
• Coordinate with ophthalmology for ongoing latanoprost management and vision assessment. 1
• Ensure dermatology follow-up for terbinafine therapy monitoring (liver function tests). 2

Critical Pitfalls to Avoid

• Do NOT add antipsychotics without first addressing reversible medical causes and attempting behavioral interventions. 5, 2
• Do NOT assume the patient understands his diagnoses or medication purposes – his denial and lack of insight indicate significant cognitive impairment. 2, 3
• Do NOT continue medications indefinitely without reassessment – approximately 47% of patients continue receiving medications after discharge without clear indication. 2, 5
• Do NOT use benzodiazepines for agitation management – they increase delirium, cause paradoxical agitation in 10% of elderly patients, and increase fall risk. 5, 1
• Avoid assuming medication adherence – implement direct observation of medication administration by facility staff. 2, 3