NU-664B Week 8 Assignment 1: APEA Review Content Completion
Value: Complete/Incomplete (100 points is Complete and 0 is Incomplete)
Due: Day 7
Grading Category: Other Assignments
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Please review the APEA live content for Neurological Disorders. As a reminder, you may view this content twice. It is recommended that you review it once for this course and once as you prepare for your certification exam. Once you have completed your first viewing, please upload your certificate of completion to this dropbox. You must upload the certificate to receive credit. This assignment does count toward your grade.
Please refer to the Grading Rubric for details on how this activity will be graded.
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Submission status
| Submission status | Submitted for grading |
|---|---|
| Grading status | Graded |
| Time remaining | Assignment was submitted 2 days 12 hours early |
| Last modified | Friday, 24 February 2023, 11:02 AM |
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| Submission comments | Comments (0) |
Questions specific to patient
1. Can you tell me your name? Do you know where you are? Do you know the date today?
My name is Saleh. I’m at the doctor’s office. I don’t know the date. But I know that it’s Thursday!
2. Do you notice problems with your memory? If so, can you provide specific examples?
I’m not really sure what my daughter is talking about! I’m just getting a little old so I can be forgetful! But I don’t think it’s a problem.
Question specific to daughter
3. Could you please provide more specific examples of your concern with her memory problems? Is it short term or long-term memory you notice being affected?
This morning when I arrived at her house, she didn’t remember that I was coming to pick her up to take her here, even though we discussed it on the phone last night. It seems to be more short term memory, like forgetting what she had for dinner, or what she did earlier in the week. Occasionally she has trouble remember the names of people or places.
4. How long have you noticed problems with your mothers memory? Is there any relationship to the concussions? Was there a problem before the concussions or only after?
She has never had memory problems before. She has always been very sharp. She made a full recovery from her concussions. Over the past few months though, she seems to be more forgetful.
Questions open to the room either patient or daughter
5. Do you feel that the memory is worsening? Has it been sudden or gradual?
Britt: Her memory loss has been gradual. I wouldn’t say that it’s worse than when I first noticed, but I’m still concerned.
6. When were the falls?
Britt: The falls were last year. We since have decluttered her house and she began strength training 3 times per week at the gym.
7. Were you seen in the hospital after the falls? Did they do imaging? Do you have the reports?
Saleh: I’ve never had any falls!
Britt: She was seen at the hospital. They did imaging and I don’t think there were any concerning findings. I can email the reports.
8. Are you taking any medications, supplements, or vitamins either prescription or over the counter? Are any of these medications or supplements new or recent dosage increases?
Saleh: I have some medications that I take. I brought a list with me. There haven’t been any recent changes, and I take my medications everyday. Do you think I should take a vitamin?
Atorvastatin 40 mg one tab by mouth once a day
Metformin 500 mg one tab by mouth once a day
Aspirin 81 mg one tab by mouth once a day
Amlodipine 5 mg one tab by mouth once a day
Chlorthalidone 25 mg one tab by mouth once a day
ibuprofen 400 mg, 2 tabs by mouth as needed for pain
9. Do you drink alcohol or use any recreational drugs?
Saleh: I don’t drink or use drugs.
10. Any vision changes? Blurred vision? Loss of vision? Visual loss?
Saleh: I don’t think I have any changes to my vision! I wear my glasses all the time.
11. Any hearing problems?
Saleh: I can hear just fine.
12. Any change in sleep patterns?
Saleh: Sometimes I wake up at night to go to the bathroom and have trouble falling back to sleep. I also like to take any afternoon nap.
Britt: I think she has been sleeping more during the day, when I go to her house in the afternoon she usually is napping.
13. Any signs of infection? Fever? Cough? Abdominal pain? Diarrhea? Problems with urination?
Saleh: I don’t feel sick at all! I’m not even sure why I’m here, I guess my daughter was worried.
Britt: No signs of infection, I am just worried about her memory.
14.Any hallucinations? Seeing, hearing, or feeling things that are not there? Any tremors?
Saleh: I don’t think so. That would be scary.
15.Any change in sleep pattern?
Saleh: Just my afternoon nap!
16.Do you live with anyone?
Saleh: I live alone. My husband died 3 years ago.
Britt: My siblings and I all live near by and spend a lot of time at her house, especially after her falls last year and the TIAs.
17.Do you drive? Do you have any problems with that?
Saleh: Of course I drive! I don’t have any trouble driving.
Britt: She is a fine driver, I am worried about her getting lost. Last week she called me from the car and couldn’t remember what errand she had gone out for.
18.Do you have any problems with completing activities of daily living? Washing, dressing, cooking ( ex. leaving stove on), managing finances? Or do you have help with these?
Saleh: No, I take care of myself just fine.
Britt: My brother said that last week when he went to her house, she had left the stove on. We have managed her finances since my father passed. She has started to need some help with grocery shopping and I always call to make sure she has taken her medications. Sometimes she has forgotten.
19.Do you have headaches? If so how often and what is the location?
Saleh: No I don’t have any headaches right now.
20. Are you feeling depressed? Or any personality changes?
Saleh: I like when my children come to visit with me. I guess I have been sleeping more during the day. Sometimes I get bored at home. I have felt that way since my husband died.
Differential Diagnosis:
1. Dementia – This is the most likely diagnosis for this patient. A patient with dementia may present with worsening memory and cognition. They may exhibit problems with language and alterations in personality. The dementia may be related to Alzheimer’s disease or multi-infarct dementia, or vascular dementia which may result after CVA (Dunphy et al.,2019). When formulating a differential, it is always important to foremost consider the most common diagnoses. This patient is 70 years old, and it is important to note that almost 15% of people older than 70 years old have dementia (Dunphy et al.,2019). In order to make the diagnosis the patient must have a disturbance in activities of daily living related to functional decline (Dunphy et al.,2019). This patient does display these criteria as her daughter reports she has started to need help with grocery shopping, she is forgetting to take her medications, she needs assistance with managing finances, and there are concerns related to her cooking due to an episode of leaving the stove on. The concussions that she experienced increase her risk for developing Alzheimer’s disease (June et al., 2020). In order to diagnose dementia, other neurocognitive disorders need to be ruled out (Dunphy et al.,2019). In order to rule in the diagnosis, I would need to have the patient complete a MMSE or MoCA screening (Dunphy et al.,2019).
2. Depression with anxiety- Depression is an extremely common psychiatric disorder in the geriatric population with 11-35 % of older adults experiencing significant depressive symptoms. Deteriorating cognitive function is frequently seen in older adults experiencing depression (Muhammad & Meher,2021). This patient does exhibit some signs of depression such as fatigue and sleeping more during the daytime. She reports some loneliness since her husband passed away. In order to rule in or out this diagnosis I would want her to complete a PH9 questionnaire for further evaluation.
3. Metabolic disturbance- Metabolic problems can result in fluid-electrolyte, and acid-base imbalances which can cause confusion. To rule in this diagnosis the provider would look for signs of dehydration on exam such as dry skin, poor skin turgor, or low-grade fever. Labs would need to be ordered for further evaluation such as a comprehensive metabolic panel, urinalysis, and thyroid function. There may also be other signs such as dizziness, altered level of consciousness, and hypotension (Dunphy et al.,2019). In this particular patient, I would be more concerned about dementia than a metabolic disturbance causing her symptoms because they have been gradual in onset and the patient is still alert. However, she is on chlorthalidone which can cause electrolyte disturbances so that is a risk factor for her. I would order labs for further evaluation and if they were normal that would rule out a metabolic disturbance and help to rule in dementia by exclusion.
4. Infectious process- Confusion can be caused by infectious processes due to tissue and organ impairment from release of toxins or ischemia which produces cell injury and death. Septicemia or bacteremia can present as delirium (Dunphy et al.,2019). I would suspect this to be less likely in this patient due to the fact that she is alert and the symptoms have been gradual in onset. However, I would still rule out infectious processes before confirming diagnosis of dementia. On physical exam I would be looking for signs of infection such as hypotension, tachypnea, tachycardia, abnormal lung sounds, or fever (Dunphy et al.,2019). I would order labs for further evaluation such as a CBC to determine if there is any leukocytosis and a urinalysis and culture to make sure there are no signs of infection.
Plan:
Primary Differential Diagnosis: Dementia
Pharmacology
If the patients MMSE or MoCa were positive and other causes of memory loss were ruled out as above, then I would discuss with the patient and daughter risks vs benefits of starting Aricept 5 mg orally daily.
I would have her continue her home medications as below based on results of labs.
Atorvastatin 40 mg one tab by mouth once a day
Metformin 500 mg one tab by mouth once a day
Aspirin 81 mg one tab by mouth once a day
Amlodipine 5 mg one tab by mouth once a day
Chlorthalidone 25 mg one tab by mouth once a day
I would recommend using Tylenol extra strength 2 caps every 8 hours as needed in place of ibuprofen due to her history of hypertension.
Non-Pharmacology
I would encourage the patient to continue exercising as being physically active is important. I would encourage the patient to be socially active as well by recommending joining local senior center to be involved with activities with others and keep the mind stimulated. I would recommend getting involved in Tai-Chi which could help with balance and help to prevent falls. I would refer the patient for home health services including nursing which could provide a home safety assessment and help with medication management and organizations such as the VNA may be able to offer home health aid services to assist with ADLs and IADLs. Elder Services would be another option. Physical therapy could help prevent falls related to her osteoarthritis.
Diagnostics: CBC with diff, CMP, A1C, lipids, TSH reflex FT4, B12, RPR, urinalysis reflex to culture.
Consults/Referrals: Referral to neuropsychiatrist to further evaluate for dementia vs. depression.
Referral to neurology
Referral for home health services/ elder services.
Referral for safety driving assessment
Would offer referral to therapist/ grief counselor.
Patient education: 1. Continue physical exercise 2. Do mind exercises such as puzzles or games 3. Be socially active 4. Follow a health diet such as the DASH diet to keep blood pressure well controlled 5. Continue to avoid alcohol 6. Have annual eye exam to reduce the risk of falls 7. Avoid sleeping for long periods during the day to help promote restful sleep at night and reduce night time awakening 8. I would educate the patient and daughter on the importance of establishing advance directives at this time such as health care proxy and MOLST 9. Would discuss need for driving safety assessment 10. Would discuss long term health care planning discuss that dementia is progressive and need for home safety assessment at this time but need to consider future living arrangements if becomes no longer safe for patient to be alone 11. Would discuss that Aricept starting dose is 5 mg but if tolerating may consider increasing to 10 mg daily 12. Would discuss that most common side effects are nausea, vomiting, and diarrhea and they should call office with development of side effects. 13. I would instruct the daughter to monitor for effectiveness of the drug by assessing if there is any improvement in functioning at home. 14. Would discuss need to report any worsening of condition and would make sure daughter and patient know to report any sudden changes in cognition right away.
(Arvanitakis et al., 2019).
(Dunphy et al.,2019)
Follow up: Would follow up in 1-2 weeks to discuss results of labs and see how patient is doing on new medication.
Health Maintenance: Would discuss the importance of continuing to exercise and discuss following a health diet such as the DASH diet. Would make sure she is up to date on all vaccinations including covid-19, flu, pneumonia, shingles, and TDAP.
(Dunphy et al.,2019).
Social Determinants of Health: It is important to consider the social determinants of health as they relate to the aging process when caring for this patient. Pain, fatigue, and weakness can lead to decreased social engagement and result in isolation and loneliness ( Perez et al.,2022). It would be important to consider that if the patient loses her license related to her memory problems this could put her at increased risk of isolation due to lack of transportation. It would be important to connect this patient with elder services for resources.
References
Arvanitakis, Z., Shah, R. C., & Bennett, D. A. (2019). Diagnosis and management of dementia:
review. JAMA, 322(16), 1589–1599. https://doi.org/10.1001/jama.2019.4782
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care (5th
ed.). F. A. Davis Company.
June, D., Williams, O. A., Huang, C. W., An, Y., Landman, B. A., Davatzikos, C., Bilgel, M.,
Resnick, S. M., & Beason-Held, L. L. (2020). Lasting consequences of concussion on the aging brain: Findings from the Baltimore Longitudinal Study of Aging. NeuroImage, 221, 117182. https://doi.org/10.1016/j.neuroimage.2020.117182
Muhammad, T., & Meher, T. (2021). Association of late-life depression with cognitive
impairment: Evidence from a cross-sectional study among older adults in India. BMC Geriatrics, 21(1). https://doi.org/10.1186/s12877-021-02314-7
Perez, F. P., Perez, C. A., & Chumbiauca, M. N. (2022). Insights into the social determinants
of health in older adults. Journal of biomedical science and engineering, 15(11), 261–268. https://doi.org/10.4236/jbise.2022.1511023
