Profile and presenting symptoms
Mrs. C is an 81-year-old Caucasian female who has been brought by her 72-year-old brother to the psychogeriatric psychiatrist at his clinic. The brother is worried about her mental state and has brought her for assessment; she has been extremely forgetful of late. Her difficulty to find words to express her thoughts had been noticed by him. Her inability to pay attention to simple tasks made him wonder about her mental status. The episodes of frequently looking confused as to what she was planning to do the next minute made the brother sure that she had set in for dementia. One moment you would see her hurrying to the refrigerator for getting a drink for him and the moment she reached it, she would open the door and look around trying to remember why she went there. The brother would not get the drink unless he reminded her.
During one of his visits, he found the door open and the gas stove burning with no pan on it. Mrs. C. was nowhere to be seen: she had gone to the neighbors. She was living alone and yet she had forgotten to close the door behind her. Earlier she must have wanted to cook or boil and forgotten to switch the gas off without probably cooking anything. The situation was risky and she could have harmed herself. Frequently she was also fumbling for words and could not complete her conversations well. Her husband’s retirement income and social security helped her through. Mrs. C had an active relationship with her brother and his daughter. Mrs. C was admitted to the older mental health unit for investigation and assessment of her mental status.
Presenting symptoms
She confesses to being confused and relates incidents of forgetfulness. On inquiry, she feels that she is a worthless woman who has become a burden to her family. Her desire to leave this world was probably a feature of her depression. Physically she was apparently in the pink of health. There was no prior treatment for psychiatric illness. However, she had ongoing treatment for osteoporosis and osteoarthritis. She had been alone in her house after her husband’s death two years back. Her weight had reduced recently as told by the brother. She pointed out that she did not have a good appetite and her sleep was disturbed.
Relevant History
Her daughter, a 52-year-old was married and lived in another state with her family of husband and three children: another cause for her loneliness. Her adult life was normal. Marriage, parenting, grandparenting, retirement, and widowhood were seemingly normal and without any unusual problems. She had no formal occupational training. Her work as a dresser in a theatre was the occupation that brought her income. Having married at 21, she had spent sixty years with her husband before he passed away. The marital relationship was not blissful according to her now. Her unkempt appearance with uncombed hair and the wrinkled dress was diagnostic in itself and she had a strong perfume smell on her.
Though oriented to person and place, she seemed unsure of the date and month. She could not name the last five prime ministers due to either ignorance or receding memory. Generally of a cooperative nature, Mrs. C was alert, labile, superficial, and an anxious lady. Though she was sure about not having hallucinations or illusions, she had delusions of her brother trying to get rid of her. Loose associations seemed to be a symptom but it was fairly easy to redirect her. Though she had cognitive deficits, she attempted to hide the shortfall by confabulations and circumstantialities. Having little knowledge about her current mental status, she could not understand why people were troubling her.
Overview of mental health problem
Mrs. C. has been provisionally diagnosed with Dementia. Dementia is the group of illnesses that cause a progressive decline in a person’s mental functioning which includes a loss of memory, intellect, rationality, social skills, and normal emotional reactions. (Statistics and dementia facts at a glance, Alzheimer’s Australia) The worldwide dementia population is 29.3 million. The commonest of dementias in the world, Alzheimer’s, accounts for 50-60% of dementias. (Draper, 2004) Vascular dementia occurs in 15-20%. A mixed variety of Alzheimer’s- vascular dementia also exists and accounts for 25 %. Dementia with Lewey bodies is gaining importance. Fronto-temporal dementia accounts for 10%.
The life expectancy in Australia is 81.3 years for women and 75.6 years for men.
(Draper, 2004). This has resulted in a larger number of people in the old ages with chances of being afflicted with dementia of some kind. However, dementia is not a natural part of aging. Being an age-related condition, occurrence under the age of sixty is not common. (Draper, 2004) Australia alone had 4.6 million new cases every year. The worldwide societal cost was the US $315.4 billion. The United States in comparison has 4.9 million people above 65 years of age (Rentz, 2008). It is the seventh leading cause of death in the US. One hundred and forty-eight billion dollars are being spent for dementia treatment there alone
Dementia is a progressive decline of the behaviors and functional well-being with the onset of disabilities. It begins very imperceptibly without warning. It runs a course of six to twelve years beginning with pre-dementia. (Draper, 2004) This stage is not recognized at the onset. When the illness is well begun, the pre-dementia stage is only recognized retrospectively. This is followed by early or mild dementia. At this stage too, friends and sometimes family do not realize the existence of dementia in the patient. Impairment of short-term memory is the main feature. Recent events like forgetting where they put the keys and what somebody told them a short while ago are common. Memories of childhood, adolescence, and adulthood are not remembered at different stages. Deterioration in memory may be realized by the sufferer. (Draper, 2004)
Word finding difficulties become evident. Personality and behavioral changes are not obvious to onlookers. The features would be attributed to age, stress, and depression. The patients lose their sociable behavior. A person with previous irritable behavior loses this. Easily worried persons become more dependent and clinging. Family tensions abound. Depression also is an early feature of the illness. Acute confusional episodes with disorientation, perplexity, agitation, hallucinations, and delusions are common. Mrs. C exhibited depression, poor memory, word-finding difficulties, and delusions. (Draper, 2004) Moderate or middle-stage dementia shows a severe deterioration of memory function and orientation. Remote memories also deteriorate. Disorientation of time will be lost. The naming of familiar people will be lost and the content of conversations becomes reduced.
What were habits (like the reading habit) would be lost. Comprehension of another’s talk and interpretation will be affected. A deterioration of executive functions and intelligence will be obvious by the difficulty in resolving daily problems. The ability to care for oneself is lesser. The trusting attitude to strangers and confidence tricksters is notable. (Draper, 2004) Personal hygiene and dressing habits become neglected. Cooking, shopping, and financial management become ‘disabled’. Minimal socializing is also noticed. The transition from independence to partial interdependence is a painful one. When there is a spouse many of the features are covert for a longer time than when the patient is living alone.
Behavior changes are obvious during the dementia stage. Aggressive behavior and wandering make things difficult for the carer. Apathy and motivation are other distressing features and the patients prefer to have a carer do everything for them. Sleep disruption is commonly seen; it becomes shorter and may consist of naps. Disinhibited behaviors can cause distress for the family and friends. Psychological symptoms are associated with neuropathological and neurotransmitter changes.
Social functions are lost. In severe dementia, all features of illness become worse. Fecal and urinary incontinence occurs. Some people stop eating necessitating tube feeds. Carers have difficulty controlling the uncooperative behaviors of some patients. In advanced dementia, patients are completely dependent on the carer. Memory cannot be tested. Lack of activity causes contractures of arms and legs. Passive exercises need to be done. Bedsores are a strong risk. (Draper, 2004).
Causes of dementia
Degenerative disorders like Alzheimer’s, Parkinsonism, Huntington’s disease; trauma; vascular causes like a stroke or a cerebrovascular accident; frontal tumors, Anoxia; toxic, endocrine, and metabolic causes, and hydrostatic causes like hydrocephalus can lead to dementia (Dementia causes, Dementia portal). Genes have some role to play in the development of dementia especially for dementia of Alzheimer’s disease
The Mini-Mental State examination
This is a test for mental status with research-based questions used mainly in the evaluation of dementia (The Mini-Mental State Examination, Alzheimer’s Society) Memory is tested with this tool. The National Institute for Health and Clinical Excellence (NICE) recommends the use of this tool for deciding about drug treatment for Alzheimer’s, one of the major types of dementias. The score is made out of a total of 30: the lower the score, the more severe the illness. The drugs are to be used only in moderate cases when the score is between 10 and 20 for treatment with Aricept (or donepezil) or Exelon or Reminyl. Treatment is stopped if the score is below 10.
Other investigations for dementia
- Full blood count, and Erythrocyte sedimentation rate
- Serum B12 and red blood cell folate
- Serological tests for syphilis
- Biochemical profile: urea, creatinine, electrolytes, calcium, and liver functions
- Thyroid functions
- Chest radiograph
- CT scan of the brain
- Magnetic resonance imaging
Current treatment modalities
There is no cure for dementia but research is bringing us closer to one. The goals of treatment are to slow down the cognitive decline of changes in thinking, memory, and perception and manage the behavioral symptoms. (Alzheimer’s Treatment overview, Fisher center)The progression of symptoms is slowed down by the drugs. Day-to-day functioning and quality of life are to be improved. Cognitive symptoms are treated using Aricept (Donepezil), or Namenda (Memantine) or Reminyl (Galantamine), or Cognex(Tacrine) as approved by the Food and Drug Administration. All the drugs except Namenda are cholinesterase inhibitors that act by delaying the breakdown of acetylcholine. This acetylcholine is the chemical found in the brain and it assists in neurotransmission and thereby is essential for memory. (Alzheimer’s Treatment overview, Fisher center)
This chemical is deficient in quantity in Alzheimer’s. In the early stages, Reminyl, Aricept, and Exelon are the most effective. Mrs. C has been started on Aricept. The drugs reduce problematic behaviors in some but others do not show any response. Aricept is taken once a day while the others twice a day.
Aricept
It is found as 5mg. and 10 mg. tablets administered once a day at bedtime with or without food. Administration slows the decline in thinking skills in the early stages. No serious side effects are found. Vomiting and diarrhea may occur. Overdose can produce seizures or sweating or bradycardia. It could interact with carbamazepine, ketoconazole phenobarbital, phenytoin, quinidine, dexamethasone, and rifampin. The patient should not drive as drowsiness is possible. The doctor should be notified if emergency procedures or surgery or dental procedures requiring anesthesia are to be done.
Mirtazapine
Mrs. C has been given this drug for depression. It acts by altering the activities of some chemicals in the brain and thereby reduces the chemical imbalance that was present. It can cause weight gain and increase cholesterol levels. Sometimes it lowers blood cell counts. It can alter moods and cause mania. Sleepiness and nausea can occur as side effects. When mirtazapine interacts with MAO inhibitors, it is strongly prohibited as even death can occur following high fever, muscle spasms, and tachycardia.
Lorazepam
This drug was administered for reducing the anxiety of Mrs. C. It is a benzodiazepine that works by slowing down the movement of chemicals in the brain.
It is contraindicated in narrow-angle glaucoma or liver disease or psychosis or pregnancy. It interacts with phenytoin, clozapine, morphine, codeine, and vecuronium.
Management Care Plan for Mrs. C.
Mrs. C may be admitted into a nursing home and placed in the care of expert carers or an assisted living residence or hospice services as she desires. A person-centered culturally-sensitive care approach is selected. Mrs. C’s physical, emotional and spiritual distress is given due respect while making efforts to maximize her comfort and well-being (Tilly et al, 2008). A safe environment is provided so that the risks of falls are diminished. Cognitive-behavioral therapy is provided so that she manages to communicate better. Nutritional supplements are given as they are necessary at her age. Symptomatic treatment would include anti-anxiety drugs or anti-depressants and sedatives. Memory deterioration is reduced using Donepezil in mild and moderate stages and Memantine (Namenda) in the later stages.
Ongoing communication among Mrs. C, her brother, daughter, and the care team would be continued so that all concerned have an understanding of how end-of-life care is to be provided. Family support would be provided to the last breath of the patient. Practice recommendations by the Alzheimer’s Association include those for communication, decision making, care coordination, physical symptoms, behavioral symptoms, psychosocial and spiritual support, staff training, and bereavement support (Tilly et al, 2008).
Nursing Implications
Nursing homes have a large number of dementia patients. 40% of the residents have dementia and 70 % cognitive impairment. (Rentz, 2008) Caring for a demented person is not easy in the midst of heavy work. Misinterpretation of behaviors is possible. Models and protocols are necessary for assisting young nurses in providing care. Person-centered care is the best type of care for the demented patient.
References
Alzheimer’s Treatment overview. Web.
Fisher Center for Alzheimer’s Research Foundation
Draper, B., (2004). Dealing with dementia: A guide to Alzheimer’s disease and other dementias. Published by Allen and Unwin Mini-Mental State examination. Web.
Alzheimer’s Society Rentz, C.A. (2008). Alzheimer’s Disease: An elusive thief. Nursing Management.
Schutte, D.L. (2006). Alzheimer’s Disease and genetics: Anticipating the questions. AJN. Vol. 106, No. 12, Lippincott, Williams and Wilkins Statistics and dementia facts at a glance. Web.
Tilly, J., Reed, P., Gould, E, & Fok., A. (2008). End-of-life care practice recommendations for assisted living residences and nursing homes serving individuals with Alzheimer’s disease. Alzheimer’s Care Today, Vol. 9, No.2, p. 113-119.