Dementia & Case Study Flashcards
Case Study: Dementia
You are the nurse working in the outpatient clinic. This afternoon, a woman brings in her father, K.B., who is 74 years old. The daughter reports that over the past year she has noticed her father has progressive problems with his mental capacity. These changes have developed gradually but seem to be getting worse. At times, he is alert, and at other times he seems disoriented, depressed, and tearful. He is forget-ting things and doing things out of the ordinary, such as placing the milk in the cupboard and sugar in the refrigerator. K.B. reports that he has been having memory problems for the past year and at times has difficulty remembering the names of family members and friends. His neighbor found K.B. down the street 2 days ago, and he did not know where he was. This morning he thought it was nighttime and wondered what his daughter was doing at his house. He could not pour his own coffee, and he seems to be getting more agitated. A review of his medical history is significant for hypercholesterolemia and coronary artery disease.
- What are some cognitive skills that may decline in an older adult?
- Verbal fluency
- logical analysis
- selective attention
- object naming
- complex visuospatial skills
- Any decline should not be assumed to be a normal part of ageing but investigated in relation to a neuro-degenerative conditions such as dementias.
- Dementia is an umbrella term that refers to the loss of cognitive functioning that interferes with daily life and activities.
- Physiologic age-related changes in an older adult can influence cognitive functioning. Name and discuss one.
Sensory changes:
Eg decreased visual acuity and accommodation, can result in decreased ability to process visual cues. Yellowing and flattening of the cornea can lead to difficulty distinguishing colors. Hearing loss affects what one hears in conversations.
- For each behavior listed, specify whether it is associated with delirium (DL) or dementia (DM).
a. Gradual and insidious onset
b. Hallucinations or delusions
c. A sudden, acute onset of symptoms
d. Progressive functional impairment
e. Personality changes with emotional lability
f. Incoherent interactions with others
g. Possible wandering behavior
h. Lucid at times, but often worsens at night
dementia a. Gradual and insidious onset.
delirium b. Hallucinations or delusions.
delirium c. A sudden, acute onset of symptoms.
dementia d. Progressive functional impairment.
dementia e. Personality changes with emotional lability.
delirium f. Incoherent interactions with others.
dementia g. Possible wandering behavior.
delirium h. Lucid at times, but often worsens at night.
You are the nurse working in the outpatient clinic. This afternoon, a woman brings in her father, K.B., who is 74 years old. The daughter reports that over the past year she has noticed her father has progressive problems with his mental capacity. These changes have developed gradually but seem to be getting worse. At times, he is alert, and at other times he seems disoriented, depressed, and tearful. He is forget-ting things and doing things out of the ordinary, such as placing the milk in the cupboard and sugar in the refrigerator. K.B. reports that he has been having memory problems for the past year and at times has difficulty remembering the names of family members and friends. His neighbor found K.B. down the street 2 days ago, and he did not know where he was. This morning he thought it was nighttime and wondered what his daughter was doing at his house. He could not pour his own coffee, and he seems to be getting more agitated. A review of his medical history is significant for hypercholesterolemia and coronary artery disease.
- Based on the information provided by K.B.’s daughter, do you think he is showing signs of delirium or dementia? Explain.
Dementia. The onset has been gradual, he has had progressive cognitive impairment (forgetting things, placing milk in the cupboard, unable to pour coffee, difficulty remembering names), and he has shown wandering behavior. Sudden onset, hallucinations, or incoherent interactions are more likely to occur with delirium.
- You know there are several types of dementia that cause cognitive changes. List 3 of these types of dementia.
- Alzheimer’s disease,
- Diffuse Lewy body dementia,
- Frontotemporal dementia (FTD)
- Posterior Corticoid Atrophy (PCA)
- Progressive primary aphasia (PPA)
- Young onset Alzheimer’s disease (YOAD)
- Vascular dementia
- How does the health care team determine the degree of cognitive impairment?
- Neuropsychological testing in the major domains of thinking and memory, verbal and expressive abilities, constructional skills, and executive functions.
Can the patient continue to handle his or her own finances, to drive, or to perform instrumental activities of daily living.
- Name 4 common cognitive assessment tools.
- General Practitioner Assessment of Cognition (GPCOG),
- Memory Impairment Screen,
- Mini-Cog, Mini-Mental State Examination (MMSE),
- 7-Minute Screen,
- Clinical Dementia Rating,
- Global Deterioration Scale,
- Brief Cognitive Rating Scale,
- MOCA- Montreal Cognitive Assessment
- CAM
CS Progress:
K.B.’s vital signs are within normal limits. He is pleasant, with coherent speech, although he does not speak unless asked specific questions. General and neurologic assessment findings are normal. On cognitive testing, he scores a 24/30 on the Mini-Mental State Examination, missing 4 points on orientation, 1 point on recall, and 1 point on intersecting pentagon drawing. Further detailed testing confirmed deficits in orientation, memory, and visual-spatial skills. He also had difficulty with the clock drawing test.
- Several diagnostic tests are ordered for K.B. From the tests listed, select those which would be used to help diagnose the type of dementia.
- Toxicology screen
- Electrocardiogram
- Electroencephalogram
- Complete metabolic panel
- Complete blood count with differential
- Thyroid function tests
- Colonoscopy
- Rapid plasma reagin (RPR) test
- Serum B12 and folate levels
- Bleeding times
- Liver function tests
- Vision and hearing evaluation
- Magnetic resonance imaging (MRI)
- Urinalysis
yes Toxicology screen
yes Electrocardiogram
yes Electroencephalogram
yes Complete metabolic panel
yes Complete blood count with differential
yes Thyroid function tests
No Colonoscopy
yes Rapid plasma reagin (RPR) test
yes Serum B12 and folate levels
No Bleeding times
yes Liver function tests
yes Vision and hearing evaluation
yes Magnetic resonance imaging (MRI)
yes Urinalysis
CS Progress:
After reviewing K.B.’s history and diagnostic test results, K.B. is diagnosed with Alzheimer disease (AD). The provider calls a family conference to discuss the implications with K.B. and his family. Fortunately, K.B. has a supportive daughter and 3 sons who live nearby who can function as caregivers.
- What neuroanatomic changes are seen in persons with AD?
Changes seen in the brain include destruction of the proteins of nerve cells of the cerebral cortex by diffuse infiltration with neurofibrillary tangles and plaques (nonfunctional tissue). These tangles and plaques are a result of the death of nerve cells within the brain.
- How would you explain AD to them?
- AD is a progressive, degenerative disorder of the brain leading to dementia
- Causes irreversible loss of memory and loss of mental functions, particularly in tasks involving language, behavior, and thinking.
- Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks.
- The rate of progression of AD varies from person to person.
- Currently there is no known cure.
- The time from the onset of symptoms until death ranges from 3 to 20
years, with an average of 8 years. - AD usually takes 3 to 15 years for a person to become mentally and physically disabled or incapacitated.
- K.B.’s son asks, “How did he get Alzheimer disease? We don’t know anyone else who has it.” How would you respond?
- We do not for certain what causes or triggers AD
- Combination of genetic, lifestyle and environmental factors that affect brain over time
- AD is NOT a normal part of ageing but age is the most important risk factor for developing AD
There are familial forms of AD but there is evidence to suggest links to viruses, autoimmune disease, deficiencies in neurotransmitters
- What are some of the experiences and support needs from the perspective of those of living with Alzheimer’s disease as evidenced in research?
- Exclusion
- Rushed and task based approaches
- Poor communication
- Uncertainty (care partners)
- Caregiver as “hostage” (care partners)
- Lack of support for care partners
CS Progress:
The family decides they will provide 24-hour supervision at home for K.B. using a combination of family, friends, and home health caregivers. K.B. receives a prescription for donepezil orally disintegrating tablet (Aricept ODT) 5 mg daily. As you review the prescription with the group, K.B.’s daughter tells you she is “so happy” because she did not know there were medications that could cure AD.
- How do you respond?
Gently explain to her that medications, such as donepezil, are not cures for AD, but they can help relieve symptoms and slow the progression of memory loss.
- What do you need to teach K.B. and his family about donepezil? Select all that apply.
a. “The best time to take donepezil is in the morning.”
b. “Swallow each tablet whole. Drink a glass of water afterward.”
c. “Notify the provider if you have trouble urinating or muscle weakness.”
d. “You may have some nausea. Taking the medication with food may help.”
e. “Keep the tablet in the blister pack until you are ready to take the medicine.”
A, C, D, E
Rationale: The tablet should not be swallowed whole but allowed to dissolve on the tongue. After it dissolves completely, the patient should drink a glass of water. Taking donepezil in the morning lessens the common side effect of insomnia (but remember discussion in class!!!)
- Recognizing that safety is a priority for K.B., you prepare a teaching plan aimed at promoting K.B.’s safety for him and his family. List 6 things you will review with them.
- Do not allow him to go out alone. Place locks on the doors and install a door alarm device that would provide warning if he opens the door.
- Register K.B. with a safe return program and obtain a wearable tracking device for K.B. to help with locating him if he wanders.
- Obtain a medical alert bracelet that has his name, address, and telephone number. Alert neighbors about K.B.’s wandering tendencies.
- He must stop driving.
- Do not allow him to do potentially dangerous activities, such as cooking, alone. Place locks on the stove dials.
Ensure that the home has good lighting, install handrails in stairways and bathroom, and remove area rugs.
