Effective Diagnosis of Dementia - Essay Example

Dementia Case Study Introduction Dementia refers to a syndrome of diseases characterized by progressive, irreversible impairment in cerebral (brain) functioning Impairments in dementia may include memory loss, loss of social and job functioning, reduced executive function, speech deficits, personality changes, as well as behavioral and psychological disturbances (Osser & Fischer, 2014, p 1). As dementia progresses, symptoms normally manifest in more tenacious language disturbances and difficulties in performing activities of daily living (Galvin & Sadowky, 2012, pp. 369). Patients with dementia normally progress from loss of higher level activities of daily living such as driving a car to loss of more basic activities of daily living such as feeding or personal hygiene (Galvin & Sadowky, 2012, pp. 369). Moreover, patients with dementia often develop cognitive and behavioral problems such as depression, apathy, anxiety, agitation, psychosis, wandering, and aggression (Galvin & Sadowky, 2012, pp. 369). The main risk factor for dementia is old age (Husband & Worsley, 2006, p 579). According to Husband & Worsley (2006, p 579) prevalence of dementia is 2% in people aged between 65-69 years and 20% to people aged between 85-89 years. Stroke and cardiovascular factors such as hypertension and hyperlipidaemia have also been found to be risk factors for dementia. Diabetes mellitus is also a risk factor for dementia because it is associated with cardiovascular risk factors that can cause or trigger unidentified progressive cerebrovascular disease (Whalley, 2002, p 370). Healthcare providers especially the general practitioners play a significant role in the diagnosis and subsequent management of dementia. Diagnosing dementia during the early stages can be a clinical challenge especially within primary care setting because of the insidious and unpredictable development of symptoms in dementia. Effective diagnosis of dementia includes assessment of the patient history, performance screening, evaluation of activities of daily living, behavioral problems, and caregiver status (Galvin & Sadowky, 2012, p 370). The case study involves a patient (Mr. David Geoffries 88 years) who presented with symptoms of dementia and has a history of CVA, glaucoma, atrial fibrillation and Type 2 diabetes. Dementia poses significant physical and psychological challenges for the patients, families and healthcare providers as well. Mr. David Geoffries’ Case Study History of Presenting Compliant Mr. David Geoffries an 88 year old man was presented in the emergency department from his home by his grandson. He presented in the acute care because he has confusion and has become increasingly incontinent of urine and faeces and has been found on the floor. The grandson explains that he has become increasingly confused and has become aggressive as he hit out at the person who was trying to bath him. Mr Geoffries appears to be alert in the ED and after some time, is finally admitted to the medical ward. He has a diagnosis of dementia and a past history of ® CVA 20 years ago. He also has atrial fibrillation, Diabetes Type 2 and glaucoma. Since his CVA, his speech has deteriorated and he has become aphasic. He also has bilateral deafness and no longer wears his hearing aids. Social/Family History Mr. Geoffries lives with his wife and his grandson. His wife is 86 years old and is not able to care of him in their home. Mr. Geoffries’ grandson who lives with them helps him. He also has children and other grandchildren who do not live with him but visits him. He enjoys a good relationship with his children and grandchildren whom they interact very well. There is a person who comes twice a week to shower him. He enjoys sleeping on a chair in front of the television or in his bed. Past Medical History CVA 20 years ago Atrial fibrillation Type 2 Diabetes Deteriorated speech Aphasic Glaucoma Bilateral deafness and no longer wears his hearing aids ALLERGIES: nil known Medications Insulin Digoxin Metformin Enteric coated aspirin Respiridone (being considered for aggression and depression) Antibiotics for urinary tract infection Zinc cream for groin application Assessment Mr. Geoffries is appears alert while in the ED. Mini-Mental State Examination (MMSE) test was used to assess cognitive function and his score was 19/30. He is very unsteady on his feet though oriented to people and place because he recognizes his children and grandchildren and is also aware that he is in a hospital. He was incontinent of urine and faeces before he came to the hospital and remains incontinent of urine and faeces. He is increasingly becoming dependent on nurses for all activities of daily living even feeding and drinking. Assessment by the ACAT team reveals that he is in need of high care. Mr. Geoffries is able to answer close ended question and is also able to play cards and poker with his children and grandchildren when they visit. He appears to sleep most of the time, every day and is disinterested in life or anything else other than food. Mr. Geoffries exhibits aggressive behavior and is observed to be very difficult with the staff who are trying to get him into the shower. Urinalysis shows that he has a urinary tract infection and a groin rash. The doctor’s assessment also indicates that he has depression. After around three weeks, Mr. Geoffries is not oriented to both time and place but is still able to answer close ended questions and play cards in spite of being deaf and aphasic. It is assumed that he has severe dementia and memory problems. Diagnosis Dementia Approach to Management The basis of dementia diagnosis is the patient’s history, collateral history from an informant such as a caregiver and physical examination as well. In this case study, Mr. Geoffries’ symptoms and behaviors showed that there was a possibility of him having dementia. A Mini-Mental State Examination (MMSE) test used to assess his cognitive function had a score of 19/30. The MMSE was used to screen Mr. Geoffries for cognitive impairment and mental status (O’Bryant et al, 2008, p 963). The highest score is 30 and a score of 23 or below than that shows a cognitive impairment (Kurlowicz & Wallace, 1999, p 1). In this case study, Mr. Geoffries had a score of 19/30 which indicates a cognitive impairment. Mr. Geoffries has a vascular risk factor (type 2 diabetes), is aged (above 75 years old), a history of CVA, deteriorated speech and is aphasic and all these are risk factors for dementia. An integrative approach to diagnosing dementia is based on all available evidence which include: the patient’s history, risk factors, outcomes of the physical examination, clinical course, neuroimaging examinations as well as cognitive impairment pattern. In this case study physical examination showed symptoms of dementia such as very unsteady on feet, incontinent of urine and faeces, sleeping disturbances, being aggressive among other symptoms (Hogan et al, 2008, p 789). The patient history of diabetes, CVA, aphasia, impaired hearing and speech problems are some of the factors that could have contributed to the patient developing dementia and thus are important in the diagnosis (Hogan et al, 2008, p 789). Family caregivers are critical in the diagnosis and management of dementia patient. In this case, the caregiver was the grandson whose information was important in the diagnosis and management of the Mr. Geoffries. In the case study, high-priority management issues included assessment of severity of Mr. Geoffries’ condition, assessment of his caretaker (grandson) abilities, assessing safety concerns, addressing advance planning and a treatment plan with well-defined goals and in this case it was decided that Mr. Geoffries needed high care and therefore he was referred to a home care facility. Clinical Manifestations of Dementia in Mr. Geoffries and Treatment People with dementia manifest behavioral and psychological symptoms of dementia that consist of cognitive symptoms and behavior disturbances. The behavioral and psychological symptoms include a range of psychological and psychiatric symptoms as well as behaviors such as agitation, apathy, psychosis, aggression, sleep disturbances, depression, wandering, and other socially inappropriate behaviors (Tampi et al, 2011, p 1). In this case study, Mr. Geoffries manifested various behavioral and psychological symptoms of dementia. First, he is not able to perform activities of daily living (ADLs), has cognitive impairment, incontinent of urine and faeces are these are common features of dementia (Kragh-Sørensen et al, 2004, p 2). He is also unsteady on feet and this might be due to disturbances in motor function which is a common problem in dementia patients (Cerejeira, Lagarto & Mukaetova-Ladinska, 2012, p 3). Mr. Geoffries is also aggressive and aggression is a common symptom in people with dementia. Aggression which is a behavioral symptom is very common in home care residents where a study found out that 86% of residents exhibit aggressive behavior (Volicer & Hurley, 2003, p 840). According to Volicer & Hurley (2003, p 842) there is always a trigger for people with dementia initiating aggressive behavior. An observation study indicated that aggressive behavior is commonly directed towards staff normally in the context of personal care (Volicer & Hurley, 2003, p 842). Similarly, Mr. Geoffries is displayed aggressive behavior during personal care when he is being assisted to bath. The resistance to care is shown through aggressive behavior results from the patient’s belief that he doesn’t need the care or for not understanding the actions of the care provider. As a result, the patient defends himself against the unwanted care (Volicer & Hurley, 2003, p 842). In this case, the staff members can use strategies to manage Mr. Geoffries’ resistance to bathing through being gentler with him, providing personalized caregiver approaches and postponing bathing him as well as by distracting him (Volicer & Hurley, 2003, p 843). Volicer & Hurley (2003, p 843) further adds that restiveness during bathing can be reduced by making the facility bathrooms more homelike an through changing from bathing using shower or bathtubs to gentle bed baths. The doctor is considering prescribing risperidone for the patient’s aggressive behavior and for depression as well. Risperidone is effective in controlling aggressive behaviors in people with dementia and therefore it is appropriate for Mr. Geoffries. In addition, Hersch & Falzgraf (2007, p 616) provide that risperidone drug is well tolerated in the elderly and does not further impair daily functioning of people with dementia when compared to other antipsychotics. Staff members are also considering using restraints on Mr. Geoffries due to his aggressive behavior. Use of restraint should be avoided because physical and chemical restraints are associated with poorer health outcomes for instance functional decrease, decreased peripheral circulation, cardiovascular stress, incontinence, muscle atrophy, pressure ulcers, agitation, social isolation, psychiatric morbidity as well as death (Cotter & Evans, 2012, p 1). Rather than using restraints on the patient, it would be advisable to investigate the reasons behind his aggressive behavior during bathing time (because he seems to be aggressive during bathing, first at home and in the home care facility) and provider a more personalized care in accordance with his preferences (Cotter & Evans, 2012, p 1). Moreover, some staff members have been mistreating Mr. Geoffries by taking to him like he is a baby and even admonishing him. Such actions by healthcare providers are likely to have adverse effects on mental health of the patient (Hoover R & Polson M, 2014, p 455). Accordingly, the staff members should be cautioned against their behavior and advised to treat Mr. Geoffries with care and compassion to avoid further distressing the patient and aggravating his dementia symptoms (Hoover R & Polson M, 2014, p 455). While in the home care facility, Mr. Geoffries is visited by his children and grandchildren who play poker and cards with him. In addition, the family place photographs around the room and start a diary of their visits. This is likely to have a positive effect on his behaviour, social interaction and wellbeing as well because these are forms of reality orientation (RO) and reminiscence therapy (RT) (Burns O, 2005, pp. 55). Reminiscence therapy entails reminding individuals with dementia using discussion and material representations regarding themselves and current events (Burns O, 2005, pp. 55). This helps in relieving pleasing former experiences. Placing family photographs around Mr. Geoffries will therefore help him in relieving the earlier pleasant experiences with his family. Interaction with his children and grandchildren and playing cards and poker is a form of reality orientation and these will help in improving his behavior, social interaction in addition to his wellbeing (Burns O, 2005, pp. 55). Management of comorbid conditions and medications Mr. Geoffries has various medical comorbid conditions. The management of comorbidities such as CVA, urinary tract infection and diabetes that the patient has, might have to be modified in presence of dementia (Mody & Juthani-Mehta, 2014, p 846). In most cases, comorbid conditions are poorly handled within a setting of dementia because healthcare providers take a nihilistic approach due to the presence of dementia or they fail to modify the care in the perspective of the patient’s declining capacity to self-manage which can consequently result to additional disability on the patient. Patients with symptomatic cardiovascular disease such as stroke are supposed to continue with treatment to lower the risk of recurrent cardiovascular events (Mody & Juthani-Mehta, 2014, p 847). Therefore, in this case study Mr. Geofrries continued with his medications for CVA, atrial fibrillation and diabetes. However in the case of diabetes, even though the treatment goals to control his blood glucose levels remained the same, the management of Mr. Geoffries diabetes should have been modified in the light of his dementia. Self-management should be reduced while the role of the healthcare providers and the family in managing the conditions such as diabetes should be increased because a patient with dementia may fail to adhere to medication regimen due to cognitive impairments such as memory problems and confusion. Blood tests should be done to assess if Mr. Geoffries is meeting his lipid targets and her diabetic treatment continued with closer supervision from staff members in the home care facility and his family as well (Mody & Juthani-Mehta, 2014, p 847). Moreover, since Mr. Geoffries has a history of CVA and atrial fibrillation her current medications were continued because it is important to decrease the risk of recurring of cardiovascular events. For the urinary tract infection that Mr. Geoffries has been diagnosed with, this may have been as a result of incontinent of urine and faeces and cognitive impairment which may hamper the required hygiene measures. Mr. Geoffries has numerous risk factors for urinary tract infection which include old age, having urinary incontinence and having type 2 diabetes (Mody & Juthani-Mehta, 2014, p 847). Evidence shows that the elderly people with dementia and comorbid conditions such as diabetes are predisposed to acquiring urinary tract infections (Beveridge et al, 2011, p 175). According to Han & Wang (2008, p 63) urine incontinent is a common problem in people with dementia and can lead to lower quality of life and other medical comorbidities such as urinary tract infection. Therefore, it can be deduced that in case of Mr. Geoffries urine incontinent was a major contributing factor to urinary tract infection. In regard to urine and feaces incontinent, the treatment for the patient should be individualized and can be treated using behavior treatments such as timed and prompted voiding, pelvic muscle rehabilitation, environmental alteration and continence aids (Han & Wang, 2008, p 63). Mr. Geoffries was treated with antibiotics for the urinary tract infection. The infection may have been as a result of asymptomatic bacteria which is common and increase with advancing age. According to Mody & Juthani-Mehta (2014, p 849) in older people, asymptomatic bacteria affects about 50 percent of people aged 70 years and above. In the elderly population, asymptomatic bacteria are normally benign (Mody & Juthani-Mehta, 2014, p 848). Therefore, it is important to establish diagnosis of symptomatic urinary tract infection in an elderly person like Mr. Geoffries who has a high prevalence of asymptomatic bacteria and progressively deteriorating urine incontinence (Nicolle & Yoshikawa, 2000, p 759). Therefore, apart from urinalysis that confirmed a urinary tract infection, it would have been necessary to carry out an assessment for new presenting signs and symptoms of genitourinary tract disease and take into account other diagnoses before administering antibiotics (Mody & Juthani-Mehta, 2014, p 849). Treatment using antibiotics elevates the incidence of adverse drug effects as well as reinfection with resistant microorganisms. As a result, asymptomatic bacteria in elderly residents of home care institutions such as Mr. Geoffries ought not to be treated with antibiotics (Nicolle & Yoshikawa, 2000, p 759). Recommendations Aggressive behaviours such as seen in Mr. Geoffries are mostly attributable to the patient attempting to avoid a discomfort, communicate his/her needs or demanding to protect his/her personal space (Ministry of Health, 2012, p 9). Therefore, it is important for the staff members to develop an individualized care plan for Mr. Geoffries. The care plan should be guided by his background, likes and dislikes, cultural values, any languages and religious factors as well as life experiences (Ministry of Health, 2012, p 9). For instance, since he is always aggressive during bathing time, it would be appropriate to find if there are personal or cultural factors behind his resistance since bathing is a very personal matter. Music therapy especially during meals and bathing can be tried on Mr. Geoffries to reduce his aggressive behavior (Osser & Fischer, 2014, p 22). Evidence shows that music is effective in reducing anxiety, stimulation cognition, increasing socialization and reducing aggression in patients with dementia (Craig, 2014, p 13). The staff members can try bright light therapy on the patient. Evidence shows that bright light therapy is effective in reducing agitation, reducing sleep disturbances and also improving cognitive performance (Alexandra et al, 2015, p 6). Conclusion The case study provides an overview of the management of a patient with dementia and other medical comorbidities. Apart from dementia, Mr. Geoffries has a history of CVA, diabetes mellitus, atrial fibrillation, bilateral deafness and aphasia. While treating patient’s conditions such as diabetes and CVA, it should be considered the patient has dementia and necessary precautions taken. The patient developed urinary tract infection and this is common in elderly people and often does not require treatment with antibiotics if it is asymptomatic infection. The patient was aggressive and respiridone was being considered for his aggressive behavior and depression. In conclusion, the paper further highlights the significance of individualized management in order to identify the triggering factors of behavior disturbances and manage them effectively. 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