Alzheimer\'s Case Study PDF

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Lecture sheet on Alzheimer patient's case study...

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University of San Francisco School of Nursing and Health Professions I: Patient Case: Overview of Case and Pathophysiology I. Overview of Case and Pathophysiology Clinical Presentation: Provide a brief and concise history of the patient’s presentation. RM is an 83 year old woman diagnosed with Alzheimer’s disease. Over the past 9 years, RM has exhibited multiple signs of Alzheimer’s which her family is very concerned about, such as wandering, misplacing important items, forgetting things, and having poor judgment. She also displayed major personality changes. RM’s first mini mental exam 9 years ago came back a 25 out of 30 and she was later placed on Donepezil to help with memory and mood (this has helped for several years). Over the past few years, however, RM’s condition has worsened; they have lost interest in their favorite activities, have had multiple outbursts of anger and occasional urinary accidents in addition to a decreased score on the mini mental state exam (now 9/30). RM’s family is considering admitting them to a long-term care facility because she is becoming unmanageable.

Pathogenesis: The case study identifies a given disease. How does this disease process evolve? Describe the sequence of cellular and tissue events that take place from the time of initial contact with an etiological agent until the ultimate expression of a disease. The disease process of Alzheimer’s disease involves the presence of neurofibrillary tangles and amyloid plaques. Neural thread proteins (tau proteins) are thought to alter in structure, as a result of inflammation, lipid abnormalities, and aging. These tau proteins are hyperphosphorylated and compose neurofibrillary tangles. While amyloid plaques aren’t concretely a cause or result of

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Alzheimer’s, it is heavily associated with the disease process. In a nerve cell, amyloid precursor proteins (APP) embed within the cell membrane and is cleaved by a protease. Improper cleaving results in the formation of β-amyloid. Accumulation of β-amyloid filaments forms amyloid plaques. Brain inflammation is also associated with Alzheimer’s disease. Increased severity of the aforementioned causes neuronal damage and atrophy; further, it causes changes regarding nerve cell communication, metabolism, and repair within the brain. (Banasik & Copstead, pg. 918-920)

Clinical Manifestations: What are the signs and symptoms of the disease? Use bold font to identify the signs and symptoms in the case study. -

Mild Stage -

Forgetfulness and subtle memory loss (inability to identify keys in hand)

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Misplacement of objects

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Inability to concentrate

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Personality changes

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Increased anxiety

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Poor judgement

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Taking longer to complete daily tasks

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Trouble handling money

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Pale and dry skin w/ senile lentigines

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Poor turgor

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Multiple minor ecchymoses notes on forearms; no other lesions or abrasions

Moderate Stage -

Difficulty remembering the past

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Disorientation (slightly conf used but cooperative elderly women in NAD) -

(but become less conf used with slowly repeated questions and simple explanations

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Episodes of wandering and getting lost

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Feeling of moodiness in social situations

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Bladder and bowel changes

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Shorter attention span

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Misperceptions about own environment

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Misidentification of objects and people

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Decline in word finding

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Difficulty learning or remembering new information

Severe Stage -

(9/30 mini Folstein exam score)

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Apraxia (Rapid alternating movements have deteriorated since the patient’s last vist)

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(Unable to tandem walk)

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Difficulty communicating (significant tic of the upper lip (2-3 twitches/minute))

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General deterioration in personal hygiene

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Difficulty swallowing

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An increased amount of time sleeping or remaining in bed

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Weight loss

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Loss of bowel and bladder control,

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Groans or grunts

(Lippincott Advisor, 2020, “Alzheimer Disease”, pp 8-10)

Epidemiology: What is the incidence, prevalence, mortality, and morbidity of the disease? Incidence: as the number one cause of dementia, Alzheimer’s disease is estimated to affect 24 million people worldwide. IN regards to prevalence, it is thought that 1 in 10 people over the age of 65 will develop Alzheimer’s disease within the United States, and the chance of developing Alzheimer’s steadily increases with age. Between 2000 and 2017, the mortality rate for patients with Alzheimer’s has increased 145%. To put into perspective, out of those over the age of 70 diagnosed with Alzheimer’s, 61% are expected to die. Overall, Alzheimer’s is the 5th leading cause of death for people over the age of 65 in the United States.

Risk Factors:

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Risk factors for Alzheimer’s include age, family history and genetics, gender (females are more likely to develop the disease), past head trauma, lifestyle and heart health (Ackley et al. 2018, page 23).

Natural History of the Disease: What is the expected course for this disease? What is the expected outcome and prospect of recovery? The course of the disease follows from mild to moderate and finally, severe symptoms that render the individual incapable of performing normal movements and neurological responses. During the mild stage of Alzheimer’s disease, the patient starts to experience slight memory changes and begins to notice difficulties with doing normal tasks. There is also a personality shift, as well as more anxiety from the loss of memory and troubles associated with Alzheimer’s disease. Then, in the moderate stage, the patient begins to have immense memory loss and has periods of wandering, and is unable to know what he/she/they are doing. They are much more restless and begin having trouble with motor tasks, such as getting out of the car. Lastly, at the severe stage, there is a complete loss of memory and regression in mental capabilities, which are accompanied by a lack of personal hygiene and more and more time spent sleeping or in bed. The disease can progress over a few years and even up to a decade, but unfortunately, there is no cure associated with this disease. Treatment is relieving the symptoms associated with the disease until there is a complete deterioration of the mind and eventually, the physical body.

II. Selected case study questions (Answer all questions related to your specific case studies): (1)Patient Case Question: What is plantar fasciitis?

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Plantar fasciitis is the “swelling of the thick [plantar fascia] tissue on the bottom of the foot.” (Lippincott Advisor, 2020, “Plantar Fasciitis Exercises”, pp.1) It is a common cause of heel pain. (2)Patient Case Question: Identify this patient’s two major risk factors for Alzheimer’s disease. The patient’s two major risk factors for Alzheimers include family history (mother and sister developed Alzheimer’s) and aging over 60. (3)Patient Case Question: Why is the patient taking allopurinol, and why is this medication effective in individuals with this condition? The patient is taking allopurinol for the condition of gout and condition of dementia and is effective in this patient’s case because allopurinol’s mechanism of action is to “reduce uric acid production by inhibiting xanthine oxidase.” Studies have found xanthine oxidase to help control aggressive behaviors that may result from dementia as xanthine oxidase has been suggested to have antiaggressive effects. (Lara et. al., pp. 1)

(4)Patient Case Question: Why is the patient taking lisinopril, and why is this medication effective in individuals with this condition? The patient is taking lisinopril to treat her hypertension. It is effective in individuals with this condition, as it “[blocks] the conversion of angiotensin I to the vasoconstrictor angiotensin II”. The drug’s method of action results in the therapeutic effect of “lowering [blood pressure] in hypertensive patients”. (Vallerand & Sanoski, pg. 164)

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(5)Patient Case Question: Why is the patient taking docusate sodium, and why is this medication effective in individuals with this condition? The patient is taking docusate sodium to treat their occasional constipation. A side effect of lisinopril is also constipation, so the administration of that medication could be another reason for the primary physician to prescribe docusate sodium. Docusate sodium is a laxative, which works on the body by “[promoting] incorporation of water into stool, resulting in softer fecal mass.” (Vallerand & Sanoski, pg. 453) Further, this allows for easier passage of the patient’s stool.

(6)Patient Case Question: What are senile lentigines? Senile lentigines, otherwise known as age spots, are hyperpigmented areas of skin that result in irregular shapes from overexposure from the sun in specific areas such as the face and the back of the hand. The occurrence of senile lentigines usually happens after the age of 50 and have sometimes been clinically found to be in areas of newly diagnoses melanoma. Common therapy treatments for senile lentigines are laser therapy and cryotherapy, and sun-protection cream can be prophylactic in preventing hyperpigmented areas of skin due to sun exposure. (Situm et. al., pp. 1)

(7)Patient Case Question: What are ecchymoses? Ecchymoses is “a large patch of capillary bleeding into tissues”; a bruise (Banasik & Copstead, pg. 398).

(8)Patient Case Question: Have the results of the patient’s mini-mental state exam improved, worsened, or remained the same since her last mental state test?

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The patient’s results from her mini mental state exam have worsened from a 25 out of 30 to a 9/30.

(9)Patient Case Question: Identify all of the abnormalities associated with this patient’s The abnormalities found in this patient is her decline in cognitive health that have caused her to constantly misplace commonly used items and wander around aimlessly, several changes in personality that have caused her to become quiet and passive as well as losing all interest and motivation in interests that she previously had. The patient also developed even more severe manifestations later on such as having difficulty with numbers, no longer able to balance a checkbook, and even forgetting to play bridge, a game that the patient has enjoyed for over 60 years. Noticeable physical changes to the patient is a significant upper tic to the upper lip and changes to her skin that come with senile lentigenes and multiple minor ecchymoses. The patient is also expressing signs of poor judgement such as leaving the house without a coat or shoes or going to the store in a nightgown. Lastly, the patient has demonstrated several sudden outbursts of anger while also becoming separated, lost, confused, angry, and then violent.

(10)Patient Case Question: Is this patient’s renal f unction normal or abnormal? The patient’s renal function is diagnosed through her BUN, and Creatinine test. The patient’s blood urea nitrogen levels are 14 mg/dL, which is within in the normal range of 8-20 mg/dL, and the patient’s creatinine levels are 1.2 mg/dL, which is well below the normal ranges, indicating “

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impaired renal perfusion (for example, associated with shock) or from renal disease due to urinary tract obstruction.” (Lippincott Advisor, 2020, “Bilirubin blood test” pp. 10) The patient’s renal function is abnormal based on the abnormal results of her creatine levels.

(11)Patient Case Question: Is this patient’s hepatic f unction normal or abnormal? The patient’s hepatic function is abnormal, as their direct bilirubin levels (0.4 mg/dL) is above the normal range (0-0.3mg/dL). High direct bilirubin levels “indicate hepatic damage” (Lipincott Advisor, 2020, “Bilirubin blood test”, pp. 13).

(12)Patient Case Question: Is this patient’s serum lipid profile normal or abnormal? The patient’s serum lipid profile is of concern because half of the patient’s lipid profile, which includes triglycerides, cholesterol, HDL, and LDL, are abnormal. The patient’s HDL levels are 39 mg/dl which is abnormal considering that normal HDL values are greater than 60 mg/dl. The patient’s LDL levels are This could indicate problems with 117 mg/dl which is abnormal considering that normal LDL values are less than 100 mg/dl. The patient’s LDL results put her at “near optimals levels” range, but this is also of concern for the patient since she is older and the abnormal HDL and LDL results could indicate increased risk of CAD or coronary artery disease. (Lippincott Advisor, 2020, “High-density lipoprotein (HDL) and low-density lipoprotein (LDL) tests:, pp. 9-10)

(13)Patient Case Question: Is this patient’s thyroid f unction normal or abnormal?

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The patient’s thyroid function is normal, as the patient’s TSH level and T4 level are within the normal range. Thyroid stimulating hormone and thyroxine are both blood level tests that indicate thyroid function. (14)Patient Case Question: Identify any laboratory blood test results in Table 38.2 that might explain the patient’s deteriorating neurological f unction. Lab results that may explain the patient’s deteriorating neurological function would be their high sodium levels, which often occurs due to impaired thirst or mental judgment. Hypernatremia in severe cases may lead to confusion and brain dysfunction (Lewis, pp. 7) RM’s D Bilirubin was also high, which may cause serious brain damage in addition to typical jaundice symptoms. This would occur if the bilirubin were to enter the brain tissue (Reiter, pp. 1).

(15)Patient Case Question. Are there any indications for treating this patient with memantine? There are indications for treating this patient with memantine, which is a medication used to manage “moderate to severe dementia/neurocognitive disorder associated with Alzheimer’s disease.” (Vallerand & Banasik, pg. 812) The patient had been experiencing memory loss, wandering, urinary incontinence, and has 2 major risk factors for Alzheimer’s. Due to the patient’s signs and symptoms, there is probable indication for prescribing memantine. (16)Patient Case Question. Multi-infarct dementia has to be ruled out as a possible cause of this patient’s changes in cognitive f unction, because this condition presents in a

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similar manner. Identify two risk factors that predispose this patient to multi-infarct dementia. Two risk factors that predispose this patient to multi-infarct dementia would be their age (83) as well as hypertension; the stress placed on blood vessels due to high blood pressure increases the chance of developing vascular problems in the brain. (Multi-Infarct Dementia, pp.4)

(17)Patient Case Question. Does multi-infarct dementia present in the same manner with a CT scan study as does Alzheimer disease? Multi-infarct dementia results in a CT scan that depicts “small areas of tissue that died from a lack of blood supply” (Krause, pp. 12), while Alzheimer’s disease presents in CT scans as “diffuse cerebral atrophy with enlargement of the cortical sulci and increased size of the ventricles” (Ramachandaran et. al, pp. 13).

Patient Case Question 18. Clinical depression in an elderly patient is often mistaken for Alzheimer disease. Is there any way to distinguish depression from Alzheimer disease in the geriatric population? Although there are many overlaps in symptoms between depression and Alzheimer’s disease, it differs in disease progression, memory loss, and cause of impaired judgement. Generally, “depression develops faster than dementia” (The Difference Between Dementia and Depression, 2020, pp. 7), which is information that can help differentiate the diseases when looking at the early stages of the disease. Although both diseases experience memory lapses, older adults with depression will be able to recall

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information if prompted. While Alzheimer’s disease causes impaired judgement due to neurological decline, older adults with depression experience impaired judgement as a result of “lack of concentration” (The Difference Between Dementia and Depression, 2020, pp. 7).

Patient Case Question 19. Why might a trial of risperidone be appropriate for this patient? Although risperidone is typically used to treat schizophrenia, it may also be appropriate in this case due to its ability to calm disturbed thinking processes, a loss of interest in daily life, and strong/inappropriate emotions (Risperidone, 2017, pp. 1). According to the case study, RM demonstrates these characteristics (i.e. outbursts of anger, a loss of interest in gardening, etc).

III. Pertinent diagnostic and laboratory tests relative to pathophysiology

11/06/ 20

HCO3 29 meq/L

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T Biliru bin

1.2 mg/dL

22-26 mEQ/L

“metabolic alkalosis: Loss of potassium due to increased renal excretion (as in diuretic therapy) or steroid overdose; Slow, shallow breathing; hypertonic muscles; restlessness; twitching; conf usion; irritability; apathy; tetany; seizures; coma (if severe) (Lippincott Advisor, 2020, “arterial blood gas analysis” pp. 14)

0.3 to 1.0 mg/dL

“Jaundice can be detected when total bilirubin is greater than 2.5 mg/dL (SI, 4.2 μmol/L). Elevated indirect serum bilirubin levels usually indicate hepatic damage.” (Lippincott Advisor, 2020, “Bilirubin blood

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test”, pp. 11) 11/06/ 20

D Biliru bin

0.4 mg/dL

less than 0.3 mg

“Elevated indirect serum bilirubin levels usually indicate hepatic damage.” (Lippincott Advisor, 2020, “Bilirubin blood test”, pp. 11)

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Na

144 meq/L

122-143 mEQ/L

“Researchers at Cornell University have found that a diet high in salt affects the flow of blood to the brain, which can result in memory problems, according to reports in the journal Nature Neuroscience.” (Being patient, 2020, pp. 1)

IV. Nursing Diagnoses Pick 2-3 appropriate nursing diagnoses that may be appropriate for this case. In your discussion please present: definition of nursing diagnosis, define characteristics or risks, related factors, suggest outcomes (1-2), and nursing interventions with rationales (3-4). Nursing Diagnosis

1. Wandering r/t “cognitive impairment” (Ackley et. al, pg. 1049) aeb getting lost in the

Expected Outcome

Nursing Intervention

(measurable)

(timeframe)

2. By the end of my shift, the client will “reduce epusides if

1. “Assess for emotional or psychological distress, such as anxiety,

Rationale

Evaluation

Outcome met: and wandering the patient was able to reduce may be understood as episodes of expressions of wandering and

1. “Rest...