Case Study 1: Wandering and Confused Elderly Patient

NURS 6540: Advanced Practice Care of Frail Elders | Week 6

In so many countries, to be old is shameful; to be mentally ill as well as old is doubly shameful. In so many countries, people with elderly relatives who are also mentally ill are ashamed and try to hide what they see as a disgrace on the family.

—Dr. Nori Graham, Psychiatrist and Honorary Vice President of Alzheimer’s Disease International

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In this quote, Dr. Graham is expressing her observations and experiences in her work with numerous international organizations. Many patients and their families experience feelings of anxiety and shame upon receiving a diagnosis of dementia, delirium, or depression. Lynda Hogg, an Alzheimer’s patient, shares her feelings that “some people don’t want to be associated with someone with an illness affecting the brain” (Alzheimer’s Disease International, 2012). As an advanced practice nurse providing care to patients presenting with dementia, delirium, and depression, it is critically important to consider the impact of these disorders on patients, caregivers, and their families. A thorough understanding of the health implications of these disorders, as well as each patient’s personal concerns, will aid you in making effective treatment and management decisions.

This week you explore geriatric patient presentations of dementia, delirium, and depression. You also examine assessment tools and treatments for these disorders. Then, you develop a question related to dementia, delirium, or depression to complete a PICO analysis. Finally, you examine literature that relates to evidence-based practices for the disorders.

Learning Objectives – Case Study 1: Wandering and Confused Elderly Patient

By the end of this week, students will:

• Assess patients presenting with symptoms of dementia, delirium, or depression
• Develop a question related to dementia, delirium, or depression
• Analyze literature that relates to evidence-based practices for dementia, delirium, or depression
• Evaluate the impact of dementia, delirium, or depression on frail elders*
• Evaluate geriatric patient care plans for dementia, delirium, or depression*

*These Learning Objectives support assignments that are assigned this week, but due in Week 8.

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Resnick, B. (Ed.). (2016). Geriatric nursing review syllabus: A core curriculum in advanced practice geriatric nursing (5th ed.). New York, NY: American Geriatrics Society.

• • Chapter 36, “Dementia” (pp. 280-291)

This chapter examines the epidemiology and societal impact of dementia. It also presents guidelines for assessing, diagnosing, treating, and managing dementia in addition to providing pharmacologic and nonpharmacologic treatment options.

• • Chapter 37, “Behavioral Problems in Dementia” (pp. 292-300)

This chapter explores clinical features of behavioral and psychologic symptoms related to dementia, as well as guidelines for assessment, differential diagnosis, and treatment. It also examines treatment for mood disturbances, manic-like behaviors, delusions and hallucinations, disturbances of sleep, hypersexuality, and intermittent aggression or agitation.

• • • Chapter 38, “Delirium” (pp. 301-310)

This chapter explores the spectrum of delirium, including the incidence and prognosis, risk factors, and diagnostic criteria for delirium. It also presents guidelines for diagnosing, treating, and managing patients with delirium, including pharmacologic therapy and drugs to reduce or eliminate as part of delirium management.

• • Chapter 40, “Depression and Other Mood Disorders” (pp. 322-329)

This chapter explores treatment strategies for depression and other mood disorders affecting older adults. It examines types of pharmacotherapy, antidepressants, as well as other treatment options, such as electroconvulsive therapy and psychosocial interventions.

Holroyd-Leduc, J., & Reddy, M. (Eds.). (2012). Evidence-based geriatric medicine: A practical clinical guide. Hoboken, NJ: Blackwell Publishing.

• • Chapter 6, “Clarifying Confusion: Preventing and Managing Delirium” (pp. 65–72)

This chapter examines strategies for screening, prevention, and management of delirium among older adults in hospital settings.

• • Chapter 7, “Preserving the Memories: Managing Dementia” (pp. 73–93)

This chapter examines dementia risk factors and screening tools for dementia. It also presents strategies for managing patients with dementia, focusing on pharmacological and nonpharmacological treatments.

• • Chapter 8, “Enjoying the Golden Years: Diagnosing and Treating Depression” (pp. 94–104)

This chapter defines depression and identifies causes and risk factors that make older adults more susceptible to depression. It also examines treatment options for managing older adults with depression.

Document: Literature Review Matrix (Word document)

Required Media

Alzheimer’s Association. (n.d.). Brain tour [Multimedia file]. Retrieved August 1, 2014, from http://www.alz.org/braintour/3_main_parts.asp

This website provides an overview of the structure and function of the brain and explores how Alzheimer’s disease changes the brain.

Discussion: Patient Presentation of Dementia, Delirium, and Depression

With the prevalence of dementia, delirium, and depression in the growing geriatric population, you will likely care for elderly patients with these disorders. While many symptoms of dementia, delirium, and depression are similar, it is important that you are able to identify those that are different and properly diagnose patients. A diagnosis of one of these disorders is often difficult for patients and their families. In your role as the advanced practice nurse, you must help patients and their families manage the disorder by facilitating necessary treatments, assessments, and follow-up care. Consider the patient presentations in the following case studies. What distinct symptoms or factors would lead you to a diagnosis of dementia, delirium, or depression?

Case Study 1

HPI: Mrs. Mayfield is a 75-year-old woman who is brought to the emergency room by the police at 11 p.m. She was found wandering and confused in a local neighborhood. The police were called when Mrs. Mayfield tried to use her key on a neighbor’s door. When confronted by the police she became abusive, confused, and frightened and looked very pale and agitated. The police could not establish her correct address and they subsequently brought her to the emergency room.

Review of Symptoms (ROS): Unable to obtain at this time.

Objective Data:

PE:

VS: Pulse 96 and regular; B/P 150/90; Axillary temperature 99°F.

General: She appears clean and well nourished, with no signs of injury, trauma, or neglect.

Her physical exam is unremarkable except –

Neuro: No gross focal neurological signs, but she is only intermittently cooperative. Her mental status fluctuates and a full neurological evaluation is not possible at this time.

Psych: A & O x 1 to person only. She has episodes of agitation and alternating withdrawal/somnolence. During the examination, it takes several attempts to gain Mrs. Mayfield’s attention to answer questions, but once focused, she rambles on in a disorganized and incoherent way.

Case Study 2

CC: “irritable and forgetful”

HPI: Mrs. White, a 78-year-old married woman, is brought to the office of her primary care provider by her husband because of increasing forgetfulness and irritability over the past 3 months. Mr. White claims that his wife has had problems for several years now, but has just gotten “worse in her memory” in the past few months. She recently misplaced her purse and accused her son of stealing it.

On three occasions, she left the stove on and boiled a pot dry, nearly causing a fire. She recently put a container of ice cream into the washing machine instead of into the freezer and her husband did not discover it for more than a week. Mrs. White claims her family wants to take her money and leave her with nothing. “No matter what they say, there is nothing wrong with me,” she states.

Past Medical History (PMH) includes: hypothyroidism, treated with Synthroid, and successful treatment of breast cancer approximately 15 years prior. She also takes over-the-counter ibuprofen for chronic lower back pain and occasional Benadryl to help her sleep at night.

Objective data: Her physical examination is within normal limits.

Case Study 3

HPI: Mr. George is a 72-year-old male who has lived alone since his wife died approximately 1 year ago. He has lived in the same house for 45 years. He is brought in by his son who is concerned that his father has lost more than 35 pounds over the past year. Mr. George admits to not eating well because “I don’t know how to cook for myself.”

PMH: He has been in good health with the exception of hypertension, which is well controlled.

Social history: He spends most of his time watching sports on television. He occasionally drinks one or two cans of beer when he is watching TV. He does go to his son’s house to visit with his grandchildren about once a week, and he says he enjoys that. He does not receive any social services, he still drives but only in the daytime, and he does not participate in any other leisure activities.

Objective data: His physical examination is normal. He responds correctly to questions, although he appears to have a flat affect.

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To prepare for Case Study 1: Wandering and Confused Elderly Patient:

• Review Chapters 6–8 of the Holroyd-Leduc and Reddy text.
• Select one of the three case studies. Reflect on the way the patient presented in the case study you selected, including whether the patient might be presenting with dementia, delirium, or depression.
• Think about how you would further evaluate the patient based on medical history, current drug treatments, and the patient’s presentation. Consider whether you would modify drug treatments, use additional assessment tools, and/or refer the patient to a specialist.

By Day 3

Post an explanation of whether you suspect the patient in the case study you selected is presenting with dementia, delirium, or depression and why. Then, explain how you would further evaluate the patient in the case study based on medical history, current drug treatments, and the way the patient presented. Include whether you would modify drug treatments, use additional assessment tools, and/or refer the patient to a specialist.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days in one or more of the ways listed below. Respond to colleagues who selected a different case study than you did.

• Suggest additional tools for assessing the patients in the case studies your colleagues’ selected.
• Offer and support an alternative perspective based on your own experience and additional research.
• Validate an idea with your own experience and additional literature search.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit! Case Study 1: Wandering and Confused Elderly Patient.