The 82-year-old man
Let’s assume the 82-year-old man arrested and then hospitalized is placed on risperidone 1 mg twice daily prior to discharge to the nursing home. In the nursing home, he becomes irritable with any change in his routine: the door has to be open by exactly 6 inches; his meals have to be identical and served on time; the newspaper needs to arrive by 8 AM. Since routine is paramount in the nursing home, the staff accommodates his need for a very regular schedule. Donepezil (Aricept) and memantine can be added as cognitive enhancers, and citalopram can be added for possible depression and obsessive features. The daughter should then be approached about reducing the risperidone dose and, hopefully, discontinuing it in the future.
Comment. A stable, routine environment is the most important intervention for managing this aggressive resident’s behavior, although he may have been helped to some degree by the adjunct medications. Once he is stable, the daughter may be able to bring him home for weekends and holidays, as long as she is advised never to surprise him with an unexpected visit or to bring home unexpected guests.