1. An 83-year-old woman who has dementia, Alzheimer type, is brought to the office for a return visit by her daughter, with whom she lives. While intermittently somewhat confused, until recently the patient had been able to handle most of her activities of daily living. In the past month, however, she has shown little interest in eating and is awake most of the night. The daughter says the patient has been seeing things, especially at night. She has been accusing her daughter of stealing from her, and has also hit her daughter. The patient has fallen twice on her way to the bathroom at night. The daughter has been giving her diphenhydramine for 1 month to help her sleep, but she says it does not seem to be helping. You have also been treating the patient with ranitidine for esophageal reflux and with amitriptyline for depression. Vital signs are normal, and physical examination is unchanged from the last visit. Her mental status has deteriorated from her last visit 4 months ago. Today she is oriented only to name, does not seem to recognize you and appears to be visually hallucinating. Her daughter says she herself is overwhelmed and wonders if it is time to consider a nursing home for the patient. Which of the following is the most appropriate response?
A
) "Her increased confusion may be due to her medicines. Let's explore that possibility first."
B
) "Her worsening mental status may be due to an inadequate diet. Let's explore that first."
C
) "It is a hard step to take, but I agree the time has come to arrange nursing home placement."
D
) "It is a little premature for that. Let's try some home health services first."
E
) "It is possible that medication might make her more manageable. Let's try a course of haloperidol."
A
) "Her increased confusion may be due to her medicines. Let's explore that possibility first."
B
) "Her worsening mental status may be due to an inadequate diet. Let's explore that first."
C
) "It is a hard step to take, but I agree the time has come to arrange nursing home placement."
D
) "It is a little premature for that. Let's try some home health services first."
E
) "It is possible that medication might make her more manageable. Let's try a course of haloperidol."
