Patient with Dementia and Depression
Patient with Dementia and Depression
Week 6 discussion
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.
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.
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.
Week 7 discussion
Discussion: Nutrition and Hydration
Geriatric patients have many nutritional and hydration concerns that impact their health and ability to acquire sufficient nutrients. Advanced practice nurses evaluating these patients must be able to account for all barriers that prevent elders from obtaining adequate nutrition, including medical conditions, transportation, finances, physiologic changes, and functional abilities. When evaluating patients, it is important to consider how they eat, what their diet consists of, and whether they have any special dietary needs that are not being met. Assessment tools, such as the Lawton Instrumental Activities of Daily Living (IADL) Scale, are an integral part of this evaluation process as they help providers identify potential obstacles for patients. In this Discussion, you assess a patient at your current practicum site and consider strategies for improving any nutrition or hydration issues.
Review this week’s media presentation, as well as 29 and 30 of the Resnick text.
Assess a patient using tools for inpatient and long-term patient care, such as the Lawton IADL Scale.
Note: You should coordinate this opportunity with the Preceptor at your practicum site.
Consider whether nutrition and/or hydration might be impacted by the patient’s functional abilities. Reflect on whether the patient is able to go out and get food to eat, cook meals, safely use the stove, etc.
Consider the patient’s diet and whether they have any special dietary needs due to medical conditions, such as congestive heart failure, end-stage kidney disease, diabetes, oral health issues, etc. Reflect on whether or not the patient is attempting to compensate for a medical issue and thus creating a deficiency or excess in his or her diet.
Based on your patient assessment, think about strategies for improving any nutrition issues that might have presented (e.g., nutritional supplements, community resources such as Meals on Wheels, referral to a nutritionist or dietician, etc.).
Week 8 discussion
Discussion: Nursing Homes in Your Community and Neighboring Communities
Nursing homes have become a viable option for geriatric patients who require routine care and need help performing basic activities of daily living, with about 3.3 million patients residing in nursing homes in the United States (Centers for Medicare & Medicaid Services, 2013). While nursing homes provide care and services to patients, problems can arise resulting in reduced quality of care and, in some cases, illness and morbidity. The severe implications of pressure ulcers make them a major concern for elders residing in nursing homes. The Centers for Medicare & Medicaid Services (2013) estimate that 7.5% of nursing home residents have pressure ulcers and about 82,000 patients develop them each year. In your role as the advanced practice nurse, you must understand factors that contribute to the incidence of pressure ulcers in order to improve patient outcomes.
For this Discussion, you examine the prevalence of pressure ulcers in nursing homes and develop strategies for increasing awareness and reducing incidence.
Review Chapter 32 of the Resnick text and Chapter 12 of the Holroyd-Leduc and Reddy text.
Select four nursing homes in your community and/or neighboring communities. Research and locate reports on these nursing homes through organizations such as Centers for Medicare & Medicaid Services.
Compare the four nursing homes you selected based on reported cases of the development of new pressure ulcers.
Think about factors in the nursing home setting that contribute to pressure ulcer issues, such as patient activity, nutrition, or the number of staff available to care for patients.
Research guidelines for the prevention of pressure ulcers. Think about how you might increase awareness among nursing home staff about the incidence and consequences of pressure ulcers in patients.
Patient with Dementia and Depression