Clinical Case Study: A 74 year old woman was admitted to a long-term care facili

Question

Clinical Case Study:

A 74 year old woman was admitted to a long-term care facility. Her son reported that, over the past year he has noticed his mother progressively having problems with her mental capacity. The changes have developed gradually but have gotten worse. He reports that at times she is alert and other times she has been disoriented, depressed, and tearful.   She has been forgetting thins and doing things out of the ordinary. His neighbor found her down the street looking for his father who passed 2 years ago. Because her behavior has gotten worse and she has become more agitated she is no longer able to live alone. She has medical diagnoses of dementia, a history of transient ischemic attacks, congestive heart failure, status post–myocardial infarction, hypercholesterolemia, and a history of urinary tract infections (UTIs), and urinary incontinence. Two weeks after her admission, she is observed by the nursing staff to be more confused and agitated over the past few days. She falls asleep during meals, and upon awakening, she is disoriented to place and time, thinking she is only visiting at the nursing home. She frequently calls out for her son and becomes combative and is always trying to leave the nursing home. These are new behaviors for this patient. The night staff report she is confused, and they have overheard her talking to her son during the night. Before this week, she was slightly confused, extremely courteous older women. The CNA reports the resident’s urine is foul smelling and dark in color.

What are some cognitive changes seen in a number of elderly?

Based on the information provided by the nursing staff do you believe the patient is experiencing delirium or dementia?

What type of test would be used to diagnose dementia?

What do you suspect has caused the most recent increase in the resident’s confusion, disorientation, and behavioral outbursts?

What medications would you suspect that she would be taking for her diagnosis of dementia?

Explanation / Answer

Cognitive abilities are brain-based skills helps the individual to perform any task from the simplest to the most complex. This includes the power to learn, remember, problem-solve, and pay attention, rather than with any actual knowledge. However cognitive decline is inevitable, but the degree of problem is not seen as common in all individuals and its onset varies among individuals.

Cognitive changes seen in a number of elderly :

In general, however, the symptoms of cognitive decline that are associated with aging include:

Slower inductive reasoning / slower problem solving - Problem solving requires two distinct types of mental skill, analytical and creative. Analytical or logical thinking includes skills such as ordering, comparing, contrasting, evaluating and selecting. Creative thinking is a divergent process, using the imagination to create a large range of ideas for solutions. This can give rise to improper analysis and reasoning capacity.

Diminished spatial orientation - Spatial skills are considered to be used for manipulating, calculating and interpreting by visual application. Diminished skills can give rise to problems with calculative understanding and analysis of harder tasks.

Declines in perceptual speed - The perceptual process is the sequence of psychological steps that a person uses to organize and interpret information from the outside world. This can lead to decline in perception and leads to disorientation and lack of understanding the external world.

Decreased numeric ability : Numeric ability helps to analyse the calculations and counting. The decline can give rise to lack of counting and calculative skills.

Losses in verbal memory: This can leads to disorienation to time ,place and person

Few changes in verbal ability : The client can present with problems with observation and with environment

Dementia is the progressive decline of memory and other thinking skills due to the gradual dysfunction and loss of brain cells due to ageing process. Whereas Delirium is most often caused by physical or mental illness, and is usually acute,temporary and reversible.

Symptoms represented in dementia are as follows;

Cognitive: memory loss, mental decline, confusion in the evening hours, disorientation, inability to speak or understand language, making things up, mental confusion, or inability to recognise common things

Behavioural: irritability, personality changes, restlessness, lack of restraint, or wandering and getting lost

Mood: anxiety, loneliness, mood swings, or nervousness

Psychological: depression, hallucination, or paranoia

Muscular: inability to combine muscle movements or unsteady walking

Also common: falling, jumbled speech, or sleep disorder

And from the above mentioned characteristics, it is believed that patient is suffering from dementia representing halluciantion, sleep cycle disturbance, disorientation,confusion in the evening hours,irritability etc.

Test to diagnose dementia:

- Complete history collection which helps to understand the patients background, family details, personal loss etc

- Head to Toe examination to rule out any abnormalities from the normal

- Mental examination to evaluate mental abilities and skills

- Glassgow coma scale to understand the level of consciousness and motor abilities

- Blood tests like Complete blood count to rule out presence of any infections,analysing liver parameters to rule out liver toxicity, analysing kidney parameters to rule out increases in urea and creatinine

- To analyse thyroid profile to rule out abnormalities of thyroid functioning as well as to rule out levels of Vitamin B12 and folate levels

- MRI Scan to rule out the difference in dementia of vascular dementia or frontotemporal dementia and this helps for proper treatment

- CT scan to rule out signs of stroke or brain tumor

- PET scan can be considered if MRI & CT scan is not certain and unsatisfactory

- EEG can be performed to rule out signs of epilepsy which is causing or worsening Dementia

The CNA report says that the resident's urine is foul smelling and dark in colour which could suggestive of infection or some liver dysfunction. And this recent abnormalities could have given rise to further deterioration like confusion, disorientation, and behavioral outbursts. The spread of infections and liver toxicity is affecting the brain function.

Medications :

- Medicines to help maintain mental function like Cholinesterase inhibitors such as donepezil, galantamine, and rivastigmine

- In some cases, the doctor may prescribe like Antipsychotic drugs, such as olanzapine (Zyprexa) and risperidone (Risperdal) and Antidepressants , especially selective serotonin reuptake inhibitors.

- She might be on druge to control her lipid levels such as statin drugs

- Drugs to control worsening of cardac illness as she is a post myocardial infarction patient, drugs to control Blood pressure and diuretics like frusemide because she is known to have congestive cardiac failure

- Antibiotics during the episode of urinary tract infection.

- Some medicines to boost her vitamin requirements like folic acid, vitamin B12

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