What case‑management recommendations are appropriate for a homebound elderly patient with a history of seizures, unspecified dementia, nicotine dependence, alcohol dependence, recurrent major depressive disorder, anxiety, an ingrown left fifth‑toe nail, smoking at bedside against facility policy, a Jehovah’s Witness relative, a limited medication regimen (two daily pills), missing prior records, tachycardia, and mild skin tenting?

Case Management Recommendations for Complex Homebound Patient

Immediate Priority: Comprehensive Medical Investigation

Before addressing behavioral or psychiatric symptoms, systematically investigate and treat reversible medical causes that commonly drive behavioral disturbances in patients who cannot clearly communicate discomfort. 1

Essential Medical Workup

• Obtain urinalysis with culture to rule out urinary tract infection, which frequently presents atypically in dementia patients and is a major driver of behavioral symptoms 1, 2
• Order comprehensive metabolic panel to identify electrolyte imbalances, renal dysfunction, glucose abnormalities, and dehydration (suggested by mild skin tenting and sluggish turgor) 2
• Complete blood count to detect anemia, which contributes to fatigue and may explain some behavioral changes 2
• Assess and treat the ingrown toenail causing 3/10 pain, as untreated pain is a major contributor to behavioral disturbances in patients who cannot verbally communicate discomfort 1
• Evaluate for constipation and urinary retention, both of which significantly contribute to restlessness and behavioral symptoms 1

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Critical Safety and Compliance Issues

Smoking at Bedside

• Implement immediate fire-safety intervention by removing smoking materials from the bedside and establishing a supervised outdoor smoking area, as this represents an imminent safety hazard 1
• Assess cognitive capacity to understand fire risk, given the dementia diagnosis and history of seizures 1
• Install smoke detectors and consider automatic fire-suppression systems if the patient continues smoking 1

Alcohol Dependence Management

• Assess current alcohol consumption objectively beyond the patient's self-report of "one beer daily," as patients with alcohol dependence often underreport consumption 1, 3
• Screen for alcohol withdrawal risk using validated tools, given the two recent ED visits for alcohol intoxication and the tachycardia (pulse 102) noted on examination 1, 3
• Educate the patient and family that alcohol worsens seizure risk, interacts with psychiatric medications, and accelerates cognitive decline in dementia 1, 3
• Consider thiamine supplementation (oral thiamine 100 mg daily) given the alcohol dependence and risk of Wernicke's encephalopathy 1

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Medication Reconciliation and Optimization

Urgent Medication Review

• Obtain complete medication list by having the family bring in all bottles (prescription, over-the-counter, supplements), as the patient reports taking "only two pills daily" despite multiple diagnoses requiring treatment 1
• Request records from the two ED visits to identify medications prescribed, treatments given, and any documented medication changes 1
• Review for anticholinergic medications (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen confusion and agitation in dementia patients 1
• Assess adherence and identify barriers, as the discrepancy between diagnoses and reported medication use suggests either non-adherence or inadequate treatment 1, 4

Seizure Management

• Verify the patient is on appropriate antiepileptic therapy for "other seizures" diagnosis, as uncontrolled seizures increase fall risk and cognitive decline 3
• Avoid medications that lower seizure threshold, including bupropion (if prescribed for depression) and high-dose antipsychotics 3

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Psychiatric and Behavioral Management

Depression and Anxiety Treatment

• Initiate or optimize SSRI therapy (sertraline 25-50 mg/day or citalopram 10 mg/day) for recurrent major depressive disorder and anxiety, as SSRIs are first-line for both conditions and have the best safety profile in elderly patients 1
• Allow 4-8 weeks for full therapeutic trial before adjusting dose or switching agents 1
• Avoid benzodiazepines for routine anxiety management due to risks of tolerance, addiction, cognitive impairment, falls, and paradoxical agitation in 10% of elderly patients 1

Dementia-Related Behavioral Symptoms

• Apply the DICE approach (Describe, Investigate, Create, Evaluate) for any behavioral symptoms that emerge 1, 5
• Implement non-pharmacological interventions first: establish predictable daily routines, ensure adequate lighting, reduce excessive noise, use calm tones with simple one-step commands, and provide structured activities 1, 5
• Reserve antipsychotics only for severe agitation threatening substantial harm to self or others after behavioral interventions have failed, using lowest effective dose for shortest duration 1

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Substance Use Interventions

Smoking Cessation Support

• Offer nicotine replacement therapy (patch, gum, or lozenge) combined with behavioral counseling, as this combination has the highest success rate 6, 7
• Consider bupropion for smoking cessation only if seizure history is thoroughly evaluated and deemed low-risk, as bupropion lowers seizure threshold 6, 7
• Provide psychoeducation about the link between smoking and accelerated cognitive decline, increased dementia risk, and worsening of existing neurological conditions 7

Alcohol Treatment

• Refer to addiction specialist or integrated substance use treatment program for alcohol dependence management 1
• Screen for co-occurring psychiatric symptoms that may worsen with alcohol use, including depression and anxiety 6
• Educate about medication interactions, particularly between alcohol and any prescribed psychotropics or antiepileptics 1, 3

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Caregiver Support and Education

Family Education

• Educate the Jehovah's Witness family members about dementia as a brain disease causing behavioral symptoms, not intentional actions, to promote empathy and reduce caregiver stress 1
• Provide psychoeducational interventions at the time of diagnosis clarification, involving active participation training for managing behavioral symptoms 1
• Address the family's concern about weight loss by assessing nutritional status, evaluating for depression-related appetite changes, and considering occupational therapy consultation for feeding strategies 2

Caregiver Strain Assessment

• Screen caregivers for depression and burnout using validated tools, as caregiver psychological strain is common and requires intervention 1
• Offer respite care options where feasible, including home-based respite to prevent caregiver exhaustion 1
• Provide ongoing support and counseling to address caregiver stress, which can inadvertently exacerbate patient behaviors 1

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Care Coordination and Follow-Up

Establish Multidisciplinary Team

• Coordinate with geriatric-trained providers including physician, nurse, social worker, and pharmacist to address the complex medical, psychiatric, and social needs 1
• Arrange physical therapy evaluation for mobility assessment, fall-risk reduction, and safe transfer techniques 1
• Consider occupational therapy for activities of daily living assessment and adaptive equipment recommendations 1

Regular Monitoring Schedule

• Schedule medical review at least every 6 months for dementia management, with more frequent visits (monthly initially) to address acute issues 1
• Monitor vital signs at each visit, particularly blood pressure and pulse, given the tachycardia noted on examination 1
• Reassess behavioral symptoms using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) to track treatment response 1
• Evaluate medication need at every visit, attempting taper of any psychotropics within 3-6 months if symptoms stabilize 1, 5

Transition Planning

• Develop advance care plan addressing the patient's wishes regarding medical interventions, keeping in mind Jehovah's Witness beliefs about blood transfusions 1
• Assess home safety including grab bars, adequate lighting, removal of hazardous objects (knives, guns), and fall-prevention measures 1
• Establish crisis plan for managing acute behavioral emergencies, seizures, or alcohol withdrawal symptoms 1, 4

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Common Pitfalls to Avoid

• Do not attribute all symptoms to "just dementia" without investigating treatable medical conditions (infection, pain, metabolic disturbances) 1, 2
• Do not add multiple psychotropics simultaneously without first treating reversible medical causes and attempting non-pharmacological interventions 1
• Do not continue medications indefinitely without regular reassessment of ongoing need and attempts to taper 1, 5
• Do not underestimate the impact of untreated pain (ingrown toenail) as a driver of behavioral disturbances 1
• Do not ignore the fire-safety risk of bedside smoking in a patient with cognitive impairment and seizure history 1