Mrs. Collin is a 79 y.o. Caucasian female living in the dementia center in assisted living

Mrs. Collin is a 79 y.o. Caucasian female living in the dementia center in assisted living

Case Study #2

The geriatric population contributes a significant proportion of patients seen in primary care settings. This patient population is unique, given the coexistence of various co-morbidities that present diagnosis and management challenges for most healthcare providers. Among the most common diseases affecting this patient population is dementia. Dementia delineates a significant decline in cognitive abilities affecting an individual’s ability to complete activities of daily living (Kumar et al., 2024). Of the various causes of dementia, Alzheimer’s disease is the most prevalent type of dementia, as it accounts for more than two-thirds of cases of dementia in individuals aged 65 years and above (Kumar et al., 2024). The behavioral and cognitive function decline associated with Alzheimer’s disease makes the disease a management priority in older adults to improve the patient’s and their caregiver’s quality of life. Therefore, this paper will discuss the diagnosis, management, evaluation, follow-up, and educational plan for a case study patient who has Alzheimer’s disease. The paper will also evaluate appropriate health promotion activities for the patient and discuss the ethical-legal issues in the case study that could be anticipated to plague patient management in real-life scenarios.

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Case Summary

The patient was seen at the request of her family to ascertain why the patient could not return to assisted living. The patient is a 79-year-old Caucasian female with Alzheimer’s disease who has been on Donepezil therapy for four years. The patient was transferred to a skilled nursing facility, followed by worsening cognition three days after hospitalization for acute gastroenteritis with dehydration. The patient is pleasant and cooperative, eats 50% of her meals and continent, and requires minor assistance with activities of daily living. On examination, she has adequate skin turgor and normal vital signs, is alert but disoriented with a mini-mental status exam score of 24/30, and is ambulatory with full muscle strength.

Discussion Questions and Answers

Assessment

A thorough history and comprehensive physical examination are required for the diagnosis of Alzheimer’s disease (Kumar et al., 2024). In the assessment of disease progression, like in the case study, it is crucial to have adequate background information on the patient’s baseline at the onset of the disease as a comparison to how the patient is feeling currently. Therefore, I would inquire about the disease’s onset, pattern, tempo, and progression from the patient’s primary caregivers and staff at the assisted living facility. I would be interested to know the changes that took place in the patient’s cognitive features, notably, their memory, behavior, personality, cognitive functions, and functional abilities as they relate to instrumental activities of daily living such as fulfilling their roles at work (Kumar et al., 2024). I would be interested in the patient’s medication history to asses for medications used during the hospitalization that could impair the patient’s cognitive function (Kumar et al., 2024). A thorough social history for alcohol and substance abuse is crucial too to ascertain accelerators of neurocognitive decline (Kumar et al., 2024). Regarding objective data, I would conduct a comprehensive neurological exam to rule out other diseases that could explain the patient’s cognitive decline. Lastly, I would perform a Mini-Cog or Montreal Cognitive Assessment Exam (MOCA) to complete the cognitive neurological exam.

I expect a normal neurological examination in the patient except for anosmia, which is common in Alzheimer’s disease patients as in other conditions such as Parkinson’s disease and traumatic brain injury (Kumar et al., 2024). However, it is also expected to detect the presence of focal neurological derangements such as aphasia, apraxia, primitive reflexes, and frontal release signs in patients with advanced stages of Alzheimer’s disease, such as the patient in the case study (Kumar et al., 2024). Therefore, the goal is to acquire a comprehensive clinical picture of the patient to guide appropriate patient management.

Differential Diagnoses

The differential diagnoses for dementia in the patient include depression, Lewy body, vascular, and frontotemporal dementia. The presence of declining cognitive and behavioral functions in the patient provides evidence to support the diagnoses of the diseases above. The impairment in memory and disorientation in the patient can also be explained by other diseases that should be ruled out, namely alcohol or drug abuse, vitamin B12 deficiency, renal insufficiency, and hypothyroidism (Kumar et al., 2024). Therefore, the diagnostic tests that would be indicated to rule out the differential diagnoses include complete blood count, complete metabolic profile, thyroid function tests, and vitamin 12 levels to rule out systemic diseases Mrs. Collin is a 79 y.o. Caucasian female living in the dementia center in assisted living.

Magnetic resonance imaging (MRI) of the brain, more so volumetric MRI of the brain, is precise and sensitive to diagnosing Alzheimer’s disease. It helps to differentiate the various causes of dementia by demonstrating structural changes that are pathognomic for Alzheimer’s disease, specifically, atrophy of the entorhinal cortex and the media temporal lobe affecting the hippocampus with resultant memory impairment in the patient (Kumar et al., 2024). Other particular tests that could be done include amyloid Positron Emission Tomography (PET), functional MRI, and Single-Photon Emission Computed Tomography (SPECT) to map out affected brain areas in Alzheimer’s disease (Kumar et al., 2024). These tests also help to set the differential diagnoses aside from Alzheimer’s disease.

Clinical Guidelines

Globally, there are fifty-three available clinical practice guidelines on the management of Alzheimer’s disease, fifteen of which were published in 2018 (Monfared et al., 2023). In the United States, the American Academy of Neurology (AAN) offers the leading clinical practice guideline for managing Alzheimer’s disease with over a thousand citations (Monfared et al., 2023). The AAN clinical guideline was developed through panel selection, extensive literature review, and critical clinical trial evidence evaluation (Monfared et al., 2023). The overall recommendation by AAN is the use of cholinesterase inhibitors and memantine for the management of Alzheimer’s disease. The clinical practice guidelines fall short in the screening recommendations for asymptomatic patients, more so utilizing biomarkers testing to screen and diagnose the disease in practice routinely (Monfared et al., 2023). Therefore, advances in developing practical screening guidelines using biomarker testing are required.

Treatment Plan

The progressive nature of the patient’s cognitive impairment in the absence of other diseases, medications, and risk factors to rule in other differential diagnoses makes the diagnosis of moderate Alzheimer’s disease acceptable. Moderate Alzheimer’s disease can effectively be symptomatically managed using memantine (Namenda) alone or in combination with Donepezil (AAR, 2024). Therefore, besides Donepezil, I agree with the patient’s primary care provider that adding Namenda would benefit the patient. Memantine reduces brain damage by inhibiting the excessive levels of glutamate causing overstimulation and hence damage to neurons in the brain (AAR, 2024). The starting dose for memantine for the patient would be 5mg daily for a week, then increase by 5mg weekly until the patient takes 10mg twice daily (Varadharajan et al., 2023). The patient should also receive physical activity and memory and orientation exercises to improve their cognitive function and overall quality of life (AAR, 2024) and enhance their ability to complete activities of daily living.

Health Promotion and Patient Teaching

The patient should be educated on the adverse effects of the new medication, such as dizziness, headaches, high blood pressure, and gastrointestinal discomfort (Varadharajan et al., 2023). The patient and their family members should be educated on the progressive nature of the disease and the anticipated neurocognitive decline that would affect the patient. The lack of a definitive cure for the disease should be tabled early, as well as the presence of alternative drugs to slow the disease progression rate, such as aducanumab and lecanemab, and their side effects (Zhang et al., 2024). The presence of worsening cognitive impairment and the need for around-the-clock skilled nursing care for the patient should be provided to the family members as the rationale why the patient requires skilled nursing care warranting skilled nursing facility admission and hence the inability to take the patient back to the assisted living facility.

The Healthy People 2030 goal for dementia, including Alzheimer’s disease, should be considered for this case goal to improve health and quality of life for people with dementia (Healthy People 2030, n.d.). An initiative to help achieve this Healthy People 2030 goal is reducing preventable hospitalization in older adults with dementia (Healthy People 2030, n.d.). Consequently, providing skilled nursing care for the patient will help boost their overall health and well-being and prevent frequent hospitalization. Further, non-pharmacological therapies such as music therapy, physical exercise, and involvement in various social events help alleviate loneliness in the patient and promote higher quality of life. Therefore, a combination of pharmacological and non-pharmacological interventions would prove effective in edging the patient closer to the ultimate Healthy People 2030 goal for dementia.

Legal-Ethical Consideration

Dementia research has been invaluable in developing effective management strategies to treat the disease. However, the involvement of cognitively impaired patients unable to consent in research presents an ethical-legal challenge for healthcare providers (David et al., 2024). The need for further study and improvement in treatment in practice necessitates appropriate dementia research. Therefore, there is a need for expanded knowledge on dementia research, specifically regarding how to ethically and legally involve dementia patients in research to further interest in the field. Additionally, close interaction with the patient’s caregivers will help to navigate the ethical-legal challenges facing interaction with dementia patients like the patient in the case study.

Circle of Caring

Using the circle of caring, the patient, their primary caregivers and caretakers, and their family members should be involved in hearing the patient’s voice throughout the patient’s case management. The caregiver who stays with the patient the longest should be the primary focal person to communicate the patient’s needs and wants as they notice changes in their condition. Additionally, the patient’s health proxy or next of kin should be involved to ensure that each care decision is in the patient’s best interest and in keeping with the patient’s care wishes.

Evaluation/Follow-Up Plan

The follow-up visit for the patient should be within two weeks to assess for neurocognitive changes between the time of the last hospital visit and the next visit. A comprehensive neurocognitive examination should be completed as part of the patient’s evaluation in the next visit to ascertain the progression of the disease. The expected changes in the patient by the next hospital visit include improvement in cognitive function, such as orientation and continued competency in completing most of her activities of daily living.

Billing

Lastly, the appropriate billing codes that I would recommend for this patient case are G30.1 for Alzheimer’sAlzheimer’s disease with late onset and G0299 for skilled nursing services by a registered nurse. According to the Healthcare Common Procedure Coding System (HCPCS), the patient is liable for billing under both level I and II provisions for the care provided in the current and next hospital visits.

Conclusion

Finally, Alzheimer’s disease diagnosis and management in the geriatric patient population is challenging. Other medical conditions requiring multiple laboratory tests to rule out the disease could mimic the disease. Imaging to identify the disease is helpful with higher specificity for the disease. However, imaging studies such as the amyloid PET scan are costly. Overall, managing the disease relies on pharmacological and non-pharmacological management to achieve the Healthy People 2030 goal for dementia, which speaks of a better quality of life, health, and well-being for older adults suffering from dementia, such as Alzheimer’s. Therefore, there is a need for healthcare providers to amass adequate knowledge in geriatric nursing and healthcare to effectively identify and treat these older adults with declining cognitive and behavioral functions.

 

References

Alzheimer’s Association Report (AAR) (2024). 2024 Alzheimer’s disease facts and figures.
Alzheimer’s & Dementia
,
20
(5), 3708-3821.
https://doi.org/10.1002/alz.13809

David, C. B. M., Giovane, D. M., Wilson, D., Truman, T., Huntley, D. J., Suleman, M., Keene, R. A., Parker, M., Sharp, J. D., & Malhotra, A. P. (2024). Considerations for legal, ethical, and effective practice in dementia research.
Brain Communications
,
6
(4), fcae211.
https://doi.org/10.1093%2Fbraincomms%2Ffcae211

Healthy People 2030 (n.d.).
Dementias
. Healthy People 2030.
https://health.gov/healthypeople/objectives-and-data/browse-objectives/dementias#:~:text=Healthy%20People%202030%20focuses%20on,memory%2C%20thinking%2C%20and%20behavior
.

Kumar, A., Sidhu, J., Lui, F., & Tsao, W. J. (2024). Alzheimer disease. Treasure Island (FL): StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK499922/

Monfared, T. A. A., Phan, N. T. N., Pearson, I., Mauskopf, J., Cho, M., Zhang, Q., & Hampel, H. (2023). A systematic review of clinical practice guidelines for Alzheimer’s disease and strategies for future advancements.
Neurology and Therapy
,
12
(4), 1257-1284.
https://doi.org/10.1007%2Fs40120-023-00504-6

Varadharajan, A., Davis, D. A., Ghosh, A., Jagtap, T., Xavier, A., Menon, J. A., Roy, D., Gandhi, S., & Gregor, T. (2023). Guidelines for pharmacotherapy in Alzheimer’s disease – A primer on FDA-approved drugs.
Journal of Neuroscience in Rural Practice
,
14
(4), 566–573.
https://doi.org/10.25259%2FJNRP_356_2023

Zhang, J., Zhang, Y., Wang, J., Xia, Y., Zhang, J., & Chen, L. (2024). Recent advances in Alzheimer’s disease: Mechanisms, clinical trials, and new drug development strategies.
Signal Transduction and Targeted Therapy
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9
(211).
https://www.nature.com/articles/s41392-024-01911-3

 

Mrs. Collin is a 79 y.o. Caucasian female living in the dementia center in assisted living

The expected length of the paper is approximately 6-7 pages, which does not include the cover page and reference page(s).

Introduction (including purpose statement)

Case Summary or Synopsis

Include a short (75-100 word) description of the patient in terms of age, sex, race, height, weight, marital status, occupation, social/cultural history, previous hospital admissions, and chief complaints on the current visit. This serves to orient the reader to the case study patient and provides an overview of clinical issues of the patient.

Discussion Questions and Answers

Conclusion

 

In regards to APA format, please use the following as a guide:

Include a cover page (this is not part of the 6-7 page limit)

Include transitions in your paper (i.e., headings or subheadings)

Use in-text references throughout the paper

Use double-spaced 12-point Times New Roman font

Apply appropriate spelling, grammar, and organization

Include a reference list (this is not part of the 6-7 page limit)

Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e., NCSBN, AANP)

 

Case Study #2:

Mrs. Collin is a 79 y.o. Caucasian female living in the dementia center in assisted living. She was diagnosed with Alzheimer’s disease by her primary care physician about 4 years ago and was started on Donepezil, which appeared to slow progression for a time. Safety concerns resulted in her placement in assisted living about 2 years ago. She recently had gastroenteritis, became dehydrated, and was hospitalized. After a 3-day stay, she was admitted to a skilled nursing facility when the assisted living staff evaluated her in the hospital and saw her cognitive impairment was much worse. Her primary care physician completed the initial exam 4 days ago, and you are asked to see her at the request of the family who does not understand why she could not return to assisted living. You review the physician’s note and he believes her AD has progressed to the moderate stage and is considering adding Namenda to Donepezil therapy.

The nursing staff reports that she appears to be confused but is pleasant and cooperative and has improved since her admission. She is eating about 50% of her meals and continues to need encouragement to drink. She is continent and able to do her activities of daily living with minor assistance. She has no known co-morbidities and is on no other medications.

Physical exam: Patient is alert and disoriented. Her MMSE is 24/30. Patient is pleasant and cooperative. Skin turgor is adequate. Patient is ambulatory with full muscle strength. Vital signs are within normal limits.

Case Study Questions:

What additional subjective and objective data would you gather?

What is the list of differential diagnoses? What additional diagnostic tests would you include to confirm or rule out each condition?

What national guidelines are appropriate to consider?

Based on your assessment and current research, what treatment would you recommend? Do you believe that adding Namenda to her medication regimen at this time should be advised?

What else should you teach your patient and her family?  Are there any Healthy People 2030 objectives that you should consider?

Are there any legal/ethical considerations?

Using the circle of caring, what or who else should be involved to hear the patient’s voice, getting him/her and family involved in the care to reach optinal health?

Mrs. Collin is a 79 y.o. Caucasian female living in the dementia center in assisted living

What is your evaluation/follow-up plan?

What billing codes would you recommend?

 Rubric:

Competency

15 Points

13 Points

 11 Points

0
 
Point

 

Assessment

 

Assessment:

Develops and demonstrates a clear & precise assessment plan supported with scholarly/evidence-based. literature, and includes objective and subjective data.

Assessment:

Develops and demonstrates an assessment plan but not fully supported with scholarly/evidence-based. literature, and may be missing one important piece of data

.

Assessment:

Develops and demonstrates a brief & vague assessment plan while missing important details of the assessment data. supported with minimal professional literature.

No paper submitted or content is missing.

Diagnostics/ Differential diagnoses

 

Diagnostics & Differential diagnoses:

Clearly describes all appropriate diagnostic tests (including sensitivity and specificity).  Thoroughly describes all relevant differential diagnoses and rationales.

Diagnostics & Differential diagnoses:

Describes all appropriate diagnostics but lacks a discussion of specificity and sensitivity for each diagnostic. Describes differential diagnoses and some rationales but omits one that should be considered

Diagnostics & Differential diagnoses:

Simply lists some diagnostics but does not discuss specificity, or sensitivity.  Describe differential diagnoses but omits more than one that should be considered and rationales.

No paper submitted or content is missing.

 

Treatment plan

Treatment plan:

Develops a clearly written set of orders inclusive of all essential elements in a treatment plan with supporting scholarly/evidence-based literature and guidelines.

Treatment plan:

Develops a clear set of written orders but omits an important order for the diagnosis, and not fully supported with scholarly/evidence-based literature and guidelines.

Treatment plan:

Develops and provides a brief set of orders for the treatment plan with more than one omission and supported with minimal professional literature.

No paper submitted or content is missing.

Evaluation/follow-up plan

Evaluation/follow-up plan:

Develops and demonstrates a clear & precise evaluation/follow-up plan for the next office visit inclusive of data and target outcomes that will need to be reviewed.

 

Evaluation/follow-up plan:

Discusses a general plan for follow-up but does not describe predictive changes and when follow-up should occur or why.

Evaluation/follow-up plan:

Describe a generalized follow- up plan that applies to all patients not the specific case.

No paper submitted or content is missing.

 

Competency

15
 
Points

14 Points

12 Points

 
0
 
Point

 

Clinical Guidelines

Thoroughly describes all relevant practice guidelines.  Clearly defines and delineates the levels of evidence that support the guidelines.

Describes relevant practice guidelines and/or describes levels of evidence to support guidelines but does not do both.

Describes a brief & vague treatment plan but lists no guidelines and does not level evidence.

No paper submitted or content is missing.

 

Health promotion/ Teaching

Develops and demonstrates a clear & precise description of the Healthy People 2030 goals and specifically relates one goal to current case.

Develops and demonstrates a clear & precise educational plan for the patient and family.

Develops a Health Promotion plan and/or discusses Healthy People 2030 and the relation to the case.

Educational topics are described but no plan is developed for the patient and family

Describes Health Promotion but does not relate back to the case.

A general educational plan is shared but is not specific to the current case. Mrs. Collin is a 79 y.o. Caucasian female living in the dementia center in assisted living

No paper submitted or content is missing.

 Competency

5 Points

4 Points

3 Points

 0 Points

 

Billing

Discusses all levels of billing that apply to the case and the most appropriate level for first visit and one follow up visit.

Discusses only the billing level that the APN may utilize without rationalization and the differences in initial and follow -up

Discusses billing levels but provides inaccurate levels or rationalization.

No paper submitted or content is missing.

 

Grammar, spelling, and punctuation

APA

There are no errors in grammar, spelling, and punctuation.

The paper meets APA format guidelines.

There are a few minor errors in grammar, spelling, and punctuation that do not detract from the meaning.

There are minor APA format errors.

There are major errors in grammar, spelling, and punctuation that do not reflect scholarly writing.

There are significant errors in format

No paper submitted.

Total Points Possible = 100