Discussion
Q-1
I would first ask the senior-assisted living facility to send their nurse over to assess the situation, take vitals including temperature, and to check the status of Mrs Josepha’s apartment while I make arrangements to have her seen in the office. I would also ask the nurse to check Mrs Josepha’s medication bottles and count them to see if she has missed any doses (Joe & ringman, 2019). I would also ask the nurse to check the patient’s bed for any signs of incontinent episodes, as well as the restrooms hopefully to see if she has urinated recently (Rodriguez-Manas, 2020). I would then call the family and update them on Mrs Josepha’s current status.
One issue will be convincing Mrs Josepha to come to the office. I hope that either phone calls from family members or conversations from staff will be able to convince her to leave her home and be able to come to the office. It is possible to travel to her, but then my assessment and treatment options would be limited by the capabilities of the living facility.
Once she arrives to the office, I can begin a full assessment on her. Since the patient has been reported that she has only picked at food it is possible that the patient is not taking much intake at all including water (Joe & ringman, 2019); (Beales, 2017). It is possible that the patient has become dehydrated and malnourished due to reports of not eating, It would be important to follow up and attempt to evaluate the patient’s fluid status (Joe & ringman, 2019);(Beales, 2017).
Due to the acute change in mental status, decrease in oral intake, I would suspect that Mrs Josepha to have developed a UTI (Rodriguez-Manas, 2020). From an active elderly woman with mild Alzheimer’s, to becoming acutely confused with a sudden change in behavior are symptoms of an elderly patinet having a UTI, possibly developing Urosepsis (Rodriguez-Manas, 2020).
Alzheimer’s disease usually progresses slowly, and has a gradual onset or worsening of symptoms (Joe & Ringman, 2019). Something that can be percieved as an exacerbation could actually be a different neurological insult such as a stroke or TIA, it would be important to assess her motor function to see if she has any new deficits, as well as confirm with the facility staff if they have noticed any changes in her coordination, balance, or overall movement that has suddenly changed when compared to today (Pushko, & Lytvynenko, 2020).
With these possible etiologies that could contribute to Mrs Josepha’s sudden change in mental status, I would speak to the family and educate them on the patient status, treatment options, the plan of care, her advanced age, frailty, and sudden changes, I would like to bring her to the hospital at first for observations and symtpom management. I would also order a head CT on arrival to rule out any type of infarction, with contrast if possible. At the hospital we would be able to monitor her input and output, as well as take cultures and administer antibiotics if needed. I would also confirm code status with family prior to Mrs Josepha arriving to the hospital to ensure her wishes are followed. I would justify this rational by the thought process that she is more at risk if we dont bring her in for observation and leave her home, rather than just bringing her in.
References:
Beales, A. (2017). An innovative approach to hydration for a patient with dementia. Nursing Older People, 29(4), 26–29. https://doi-org.lopes.idm.oclc.org/10.7748/nop.2017.e898
Joe, E., & Ringman, J. M. (2019). Cognitive symptoms of Alzheimer’s disease: clinical management and prevention. BMJ (Clinical Research Ed.), 367, l6217. https://doi-org.lopes.idm.oclc.org/10.1136/bmj.l6217
Pushko O. O., & Lytvynenko N. V. (2020). Modern Aspects in the Paradigm of Acute Hemispheric Ischemic Stroke: Features of Clinical Presentation, Screening, Therapeutic and Neuro-Rehabilitation Prospects. Вісник Проблем Біології і Медицини, 3. https://doi-org.lopes.idm.oclc.org/10.29254/2077-4214-2020-3-157-30-35
Rodriguez-Mañas, L. (2020). Urinary tract infections in the elderly: a review of disease characteristics and current treatment options. Drugs in Context, 9, 1–8. https://doi-org.lopes.idm.oclc.org/10.7573/dic.2020-4-13
Q-2
A transischemic attack (TIA) is a medical emergency in itself (Panuganti, Tadi & Lui, 2020). Essentially it an episode of neurologic dysfunction due to intermittent ischemia (Panuganti, Tadi & Lui, 2020). The etiology of TIAs are considered multifactorial, but the subtypes all prevent bloodflow to the brain for a short period of time (Panuganti, Tadi & Lui, 2020). Some examples include large artery atherothrombosis, cardiac embolism, small vessel occlusion, arterial spasms, and some uncommon onse such as vascular disection or vasculitis (Panuganti, Tadi & Lui, 2020).
TIAs have moved from overall time based diseases to now tissue based, as symptoms can last from minutes to up to an hour (Panuganti, Tadi & Lui, 2020). However, the most important thing about TIAs is that once you experience one, there is now a time window of extreme risk of a subsequent ischemic stroke for the next 48 hours (Panuganti, Tadi & Lui, 2020).
Strokes are more severe interruptions in blood flow to the brain, they are longer lasting, and can have debilitating life-long lasting effects (Hui, Tadi, & Patti, 2020). There are essentially two subcategoris which are ischemic and hemmorhagic (Hui, Tadi, & Patti, 2020). Ischemic is when the blood supply is obstructed due to an embolis of some type, mostly embolic, but plaque, fat, bacterial, and air can also cause embolisms (Hui, Tadi, & Patti, 2020). Hemmorhagic strokes are usually caused by a ruptured vessel in the brain causing a decrease in blood flow to an area of the brain resulting in ischemia of the affected tissues (Hui, Tadi, & Patti, 2020).
First, the patient with a history of TIAs is experiecing another TIA, should have gone immediately to the closest emergency room for proper management and treatment of their disease process (Panuganti, Tadi & Lui, 2020). His persistent symptoms indicate a possible ischemic stroke of some kind, as a hemmorhagic stroke would laso be accompanied by an increasing headache due to increasing intercranial pressures (Hui, Tadi, & Patti, 2020). A persistent numbness and tingling accompanied with a loss of strength would also help indicate the patient is having an ischemic stroke as well (Hui, Tadi, & Patti, 2020).
I would expect to confirm the patient’s system on exam, with the possibilty of limb ataxia on the right, limb drift, and an elevated NIHSS scale (Hui, Tadi, & Patti, 2020);(Panuganti, Tadi & Lui, 2020).
The key element to this patient’s likelyhood that he had a stroke is the persistent numbness and tingling with weakness that has been continuous for the last 36 hours (Hui, Tadi, & Patti, 2020). My immediate reccomendation would be to send this patient to the closest ER, hopefully a comprehensive stroke center, where a head CT can be done to rule in or out an ischemic stroke (Hui, Tadi, & Patti, 2020);(Panuganti, Tadi & Lui, 2020). If this patient had a confirmation of a stroke, hopefully the patient would qualify for a cerebral thrombectomy or TPA (Hui, Tadi, & Patti, 2020);(Panuganti, Tadi & Lui, 2020).
References:
Hui, C., Tadi, P., Patti, L. (2020). Ischemic Stroke. In: StatPearls. Treasure Island: StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK499997/
Panuganti, K.K., Tadi, P., Lui, F. (2020) Transient Ischemic Attack. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK459143/
Q-3
Dementia is an impairment of brain function which results from an exogenous insult or an intrinsic process affecting cerebral neurochemistry and anatomic damage to the cortex, subcortex, or deeper. As the disease progresses, many affected individuals develop psychological problems in behavior issues such as agitation, irritability, aggression, depression, delusions, hallucinations, wandering, and sleep disorders (Imtiaz, Khan, & Seelye, 2018).
The key priorities are supportive care, including patient safety and nutrition, ruling out potential pathologic sources with diagnostics and laboratory workups that might cause the symptoms, and managing symptoms through pharmacologic and non-pharmacologic means.
Investigating whether Josepha is having delirium vs. symptoms of dementia is crucial in the treatment plan’s appropriateness. Delirium typically affects older people with a wide variety of ailments and most commonly caused by a metabolic disorder(adverse drug reaction or drug-drug interaction), toxins, infections, anatomic disorders, environmental disorders, and other causes such as fever, postictal states, urinary retention and fecal impaction (Lippman & Perugula, 2017). Ordering laboratory workups such as CBC, BMP, liver function test, thyroid function test, Vitamin B12, folate level, urinalysis, and MRI to determine the presence of neoplasm is necessary to rule out pathological sources. Once dementia symptoms have been established, supportive care should be provided to keep the patient safe and well-nourished.
According to Hartig (2018, p. 421), a predictable routine and familiar environment may help minimize the risk of behavior episodes such as paranoia and other behavioral and psychological symptoms of dementia. An attempt to maintain nutritional status by offering and encouraging regular meals of high nutritive value and providing positive reinforcement in eating should be made.
I will review and consider increasing Josepha’s Alzheimer’s disease maintenance medication as the symptoms of agitation, and the behavioral problem can be a sign of disease progression. Additionally, the combination of non-pharmacological treatment such as reminiscence therapy and music therapies has proven to be very beneficial in addressing behavior issues and has been recommended to reduce behavioral and psychological symptoms of dementia (Imtaz et al., 2018).
Essential education should focus on the patient’s safety and reduction of caregiver’s distress. Patient safety education should include fall precautions and safety concerns (medication cabinet access, door alarms, secure environment, etc.). Family and caregiver’ education should include a respite care program for caregivers, mindfulness-based stress redution, and other exercises that would improve their well-being (Hartig, 2018, p. 422).
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