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Visit summary

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Generated for Dr. Sarah Chen · Neurology
Caregiver visit brief

Eleanor M.

Jan 18 - Apr 18, 2025 (90 days)

Summary

Eleanor remains stable on Donepezil + Memantine. New pattern: late-afternoon agitation (sundowning) on 11 of 30 days, clustering on nights with <7h sleep. Two falls (no injury), both after 8 PM. Mood predominantly calm; family reports best engagement during music and photo sessions.

Avg BP
128 / 78
stable
Avg resting HR
72 bpm
stable
Weight
138 lb
-2 lb

Cognitive

  • MoCA: 19/30 (Jan 14, 2025) - unchanged from Oct
  • Family-reported word-finding difficulty: moderate, stable
  • New: occasional misidentification of Ben (son) as her brother

Behavior & function

  • Sundowning: 11 of last 30 days, typically 3:30 - 5:00 PM
  • Sleep: avg 6.9h; 8 restless nights linked to next-day agitation
  • Two falls (both at night, no injury); rug removed in hallway

Questions for Dr. Sarah Chen

  • 1. Is a low-dose Trazodone trial appropriate for evening agitation?
  • 2. Should we add a daytime structured activity to anchor 3-5 PM?
  • 3. Any concern with current Memantine dose given new misidentification?
Compiled from Grace, Maya, Ben's daily entries and the medication log.

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