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Mr C was a 79-year-old man living with his wife in a hostel. He had accepted this placement two years previously after a minor stroke left him with weakness in his right arm. His wife had suffered from Alzheimer's disease for several years and he had devoted himself to her care. In the hostel they shared a pleasant double room and Mr C was initially sociable with the other residents, although quite protective of his wife. After a couple of months he began refusing to allow his wife to eat meals with the other residents or join in social activities. He became irritable with the staff and accused them of encouraging his wife to leave their room at night. There was some concern that he was becoming verbally aggressive towards her.

At his own insistence Mr C had not been medically reviewed for some time and had always been reluctant to take any form of prescribed medication. With persuasion he allowed his wife's general practitioner to undertake a brief examination. This revealed mild hypertension and it became more obvious that Mr C was concerned that his wife had developed a liaison with one of the other residents and that the staff were facilitating meetings between his wife and this person at night. In reality, his wife wandered at night and the staff would allow her to watch television, so as not to disturb other residents.

As Mr C refused to consider any medication, he was referred for psychiatric assessment. Further mental state examination revealed delusions of persecution and jealousy, but no perceptual disturbance. Cognitive testing showed widespread deficits, although his short term memory was relatively spared. The general practitioner, having developed some rapport with Mr C, persuaded him to have a CT scan of the head. This suggested a diagnosis of multi-infarct dementia. By this time Mr C's irritability towards his wife was escalating and there was concern that they may need to be separated. Confronted with this possibility, he became more accepting of treatment and began taking haloperidol 1 mg at night.

Over three weeks Mr C's delusional ideas resolved, but he developed a fine resting tremor. The haloperidol was changed to risperidone 1 mg at night and he had no further side effects.

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