Dementia, Delirium and Depression - Mr David Geoffries - Case Study Example

Dementia, Delirium and Depression: A Case Study Introduction Dementia is among the most common condition during old age and it causes distressing suffering and dysfunction on people with dementia (Desai & Grossberg, 2001, p 94). Dementia is associated with cognition and self-care deficits as well as non-cognitive psychiatric and behavioral symptoms (Desai & Grossberg, 2001, p 94). Behavioral symptoms of dementia include psychiatric manifestations such as depression, hallucinations, psychosis, delusions, agitation, aggression, apathy, sleep disturbances and executive dysfunction (Gitlin, Kales & Lyketos, 2012, p 2024). Common behaviors in dementia encompass repetitive vocalizations, resistance to care, wandering and being argumentative and these behaviors are often very challenges to the carers and families (Gitlin, Kales & Lyketos, 2012, p 2024). The highest risk factors for dementia are old age, family history and genetic susceptibility genes (Baumgart et al, 2015, p 721). Other risk factors for dementia are cardiovascular risk factors such as diabetes, obesity and hypertension and also depression (Baumgart et al, 2015, p 722). General practitioners play a vital role in diagnosis and management of dementia because basically they are the first point of contact for individuals with suspected cognitive impairment or dementia and they also have the main responsibility for the ongoing management of patients after confirmation of diagnosis (Murphy et al, 2014, p 2). The first step to effective treatment of dementia is diagnosis clarification but this can be challenging because aged population mostly have other medical comorbidities that can partly cause cognitive impairment (Gagliardi, 2008, p 383). Therefore, when assessing elderly patients, it is vital to evaluate their cognitive status and establish their baseline capacity to function and carry out activities of daily living (ADLs). Determining a patient’s ADLs enables the healthcare provider to identify and act on changes (Gagliardi, 2008, p 383). This paper focuses on a case study of Mr. David Geoffries (88 years) who has dementia and a past history of CVA 20 years ago. The patient also has atrial fibrillation, Diabetes Type 2 and glaucoma. Case Study for Mr. David Geoffries History of Presenting Compliant Mr David Geoffries is an 88 year old man who has been transported to the ED from his home. He was brought into the acute care hospital by his grandson because he has confusion and has become increasingly incontinent of urine and faeces and was found on the floor. He is accompanied by his grandson who speaks for him and explains that his grandfather has become increasingly confused and has hit out at the person who was trying to shower him. Mr Geoffries appears to be alert in the ED and after some time, is finally admitted to the medical ward. Social/Family History Mr. Geoffries lives with his wife who is 86 years old. Even though the wife is reasonably healthy, she is not able to care for her husband in their home. Mr. Geoffries also lives with his grandson who assists him. There is a person who comes twice a week to shower him. Mr. Geoffries enjoys sleeping on a chair in front of the television or in his bed. He has children and grandchildren who visit him regularly and interact with him. Past Medical History Atrial fibrillation Diabetes Type 2 CVA 20 years ago Glaucoma Deteriorated speech due to CVA Aphasic Bilateral deafness and no longer wears his hearing aids ALLERGIES: nil known Medications Metformin Insulin Digoxin Enteric coated aspirin Antibiotics for urinary tract infection Zinc cream for groin application Respiridone (being considered for depression) Medical Assessments On observations, Mr. Geoffries appears alert in the ED. He is extremely unsteady on his feet but appears oriented to place because he appears to be aware he is hospital. His Mini Mental State Examination score is 19. He is also oriented to person as he seems to recognize his children who visit him. He is increasingly dependent on nursing staff for all activities of daily living including eating and drinking. ACAT team assesses him and establishes that he needs high care. Mr Geoffries remains incontinent of urine and faeces. He is able to answer close ended questions and can play cards and poker with his children and grandchildren. He is aggressive and difficult with staff. Urinalysis is performed and indicates he has a urinary tract infection and a groin rash. Depression score reveals that he is depressed. After about three weeks, Mr. Geoffries is not orientated in time and place. However, he is still able to answer close ended questions and play cards. Diagnosis Severe dementia and memory problems Discussion According to both subjective and objective data that was collected, it was clear that Mr. Geoffries was exposed to various risk factors for dementia. These include old age since he is 88 years old, diabetes type 2, deteriorated speech due to CVA, aphasia and bilateral deafness as well. In addition, the medications used in treating Mr. Geoffries other comorbidities can be aggravating his condition. For example, digoxin has been shown to have side effects such as confusion, depression, anxiety and losing interest in the normal activities. Physical and Psychosocial Manifestations of Dementia Mr. Geoffries exhibits various physical and psychosocial manifestations of dementia. According to Kar (2009, p 79) behavioral and psychosocial symptoms of dementia are an essential component of dementia syndrome. Tampi et al (2011, p 1) also stipulate that behavioral and psychological symptoms of dementia consist of non-cognitive symptoms and behaviors that are common in people with dementia and they include various psychological reactions, psychiatric symptoms, and behaviors. Kales, Gitlin & Lyketsos (2014, p 1) define behavioral and psychological symptoms of dementia as signs and symptoms of disturbed perception, thought content, mood, or behavior. They consist of agitation, depression, apathy, psychosis, aggression, sleep problems, wandering, and other various socially unsuitable behaviors (Kales, Gitlin & Lyketsos, 2014, p 1). In this case, the behavioral and psychological symptoms of dementia in Mr. Geoffries include being aggressive and difficult with staff, depression as assessed by the doctor, sleep problems as he seems to spend most of the time sleeping and confusion among others. In addition, his Mini Mental State Examination score is 19 and this indicates that he has cognitive impairment. Lower scores show higher cognitive impairment (range: 0-30) and in this case a score of 19 indicated that Mr. Geoffries has moderate cognitive impairment (National Ageing Research Institute, 2011, p 2). The patient’s inability to carry out activities of daily living is also manifesting cognitive impairment common in people with dementia. Mr. Geoffries is incontinent of urine and faeces and depends on other people for activities of daily living such as bathing, eating and even drinking. According to Kragh-Sørensen et al (2004, p 2) individuals with severe cognitive disability requires help with almost all aspects of daily living. The most visible indicator of dementia is the progressive incapacity to carry out activities of daily living and the ensuing loss of independence (Kragh-Sørensen et al, 2004, p 2). Progressive decline in the cognitive, functional and behavioral aspects in the long run bring the individuals with dementia to the later stages of dependency and often to institutionalisation, which is allied to elevated need in caregiver aid (Kragh-Sørensen et al, 2004, p 2). This is evident in Mr. Geoffries condition where he is progressively becoming dependent on other people for activities of daily living which eventually led to him being institutionalized in a residential aged care after being assessed by the ACAT team as requiring high care. Cerejeira, Lagarto & Mukaetova-Ladinska (2012, p 3) explain that disturbances in motor function are common in people with dementia. The patient in the case study exhibits disturbances in motor function. Mr. Geoffries is extremely unsteady on his feet and also even though his speech deterioration and aphasia started when he had CVA 20 years ago, dementia may have contributed to this. Being unsteady, speech deterioration and aphasia indicate motor retardation in the patient. In patients with dementia, motor retardation is manifested by reduced movements and speech as well as decrease in some of the spontaneous body movements (Cerejeira, Lagarto & Mukaetova-Ladinska, 2012, p 3). Additionally, studies have shown that language impairments such as loss of conversation and communication problems and difficulties in finding words can be the most prominent first symptoms of individuals with neurodegenerative disorders such as dementia (SPA, 2012, p 6). SPA (2012, p 6) further adds that primary progressive aphasia is a clinical dementia syndrome typified by the slow language dissolution without impairing other cognitive domains. Urinary Tract Infection There are various factors that predispose older people to urinary tract infections such as use of urine external collection devices. In addition, asymptomatic bacteriuria is very common in patients with incontinent of urine and faeces and with cognitive impairment (Beveridge et al, 2011, p 175). Neurological conditions like dementia are allied to impaired bladder emptying. Evidence also shows that patients with type 2 diabetes have higher prevalence of asymptomatic bacteriuria where contributing factors comprise neurogenic bladder and poor glycemic control (Beveridge et al, 2011, p 175). Mr. Geoffries is incontinent with urine and faeces, has cognitive impairment due to dementia and also has type 2 diabetes. All these factors could have contributed to him having urinary tract infection. Treatment and management of urinary tract infection in individuals with dementia such as Mr. Geoffries is supposed to be consistent with their therapeutic goals such as patient comfort versus life prolonging. Treatment of UTIs in elderly patients can be challenging because antibiotics can cause side effects such as nausea and vomiting (Pop-Vicas et al, 2008, p 1278). Therefore, it is important for the healthcare providers to take into consideration the values of Mr. Geoffries and his family and requests when making decisions as per his advanced care directive in order to avoid over-treatment. Basically, all new residents in residential home care instituiones such as Mr. Geoffries should have an advanced care directive which should encompass documented decisions regarding future antibiotic use and palliative alternatives. D’Agata, Loeb & Mitchell (2013, p 64) further add that inappropriate use of antibiotics in patients with dementia is of major concern because these patients might also have individual factors allied with sheltering bacteria including bacteria that are resistant to antibiotics such as faecal incontinence present in Mr. Geoffries. Furthermore, the patient is receiving substantial aid with activities of daily living from healthcare providers and this could have led to transmission of bacteria. Management and Care The multiple impairments of dementia mostly lead to mood disorders, sleep disturbances, aggression, agitation and other disinhibited behaviors. This can be distressing to both the patient and the caregiver and often triggers the patients to be referred to primary care and placement in home care institutions. Mr. Geoffries was referred to home care because he was found to need high care. In this case the patient was not prescribed any medication for dementia and the manifesting cognitive impairments and behavioral disturbances. This is appropriate because treatment using antipsychotics among elderly patients should be minimized. However, since Mr. Geofrries is aggressive a behavior which warrants pharmacological intervention, an ideal medication which has rapid onset, sustained action and minimal somatic and cognitive side effects should be administered. Antipsychotics such as low dose of haloperidol can be administered since haloperidol has been successfully used in controlling behavior and psychological symptoms of dementia among the elderly (Hersch & Falzgraf 2007, p 615). Alternatively, antipsychotics risperidone or olanzapine can be administered since they have been shown to have the best evidence of efficacy in treatment of neuropsychiatric symptoms. The doctor is considering prescribing risperidone for the patient’s depression. This is advisable because risperidone can also treat other dementia symptoms in the patient. Risperidone is effective in controlling aggression as well as other psychotic symptoms in individuals with dementia and hence it would be suitable for Mr. Geoffries who is aggressive. Risperidone is well tolerated among the elderly and it has been shown not to further impair the daily function of elderly people with dementia (Hersch & Falzgraf 2007, p 616). However, use of any antipsychotic therapy for the patient should be monitored adequately and the goal should be to improve aggression without impairing other dementia aspects like cognition, function and quality of life (Hersch & Falzgraf 2007, p 615). Mr. Geoffries seems to be having severe dementia as manifested by the symptoms and memory problems. Therefore, it would be appropriate to use palliative care instead of aggressive care as demonstrated in the case study (Rose & Lopez 2012, p 4). The staff is considering using restraints on Mr. Geoffries because of his aggressive behavior. This should be avoided because use of restraints in the elderly is associated with poor health outcomes such as functional decline, reduced peripheral circulation, cardiovascular stress, incontinence, muscle atrophy, pressure ulcers, infections, agitation, social isolation, psychiatric morbidity and even death (Cotter & Evans, 2012, p 1). It is therefore recommendable to investigate the cause of Mr. Geoffries’ agitation and address the issue. Impaired memory and confusion may be increasing agitation. The patient may also be resisting care (bathing) and becoming aggressive because he feels lost and afraid yet he is unable to express himself and communicate his concerns due to language deficits allied with dementia (Cotter & Evans, 2012, p 1). Best practice recommends personalized care that allows the patient to be nursed safely and without any restraint (Cotter & Evans, 2012, p 1). It would therefore be important for the healthcare provider to gather information from the patient’s family in order to have adequate knowledge regarding his normal behavior and function to be able to provide personalized care to Mr. Geoffries. It would also be appropriate to assess for the patient’s unmet needs and behavioral changes. The confusion and aggression should be perceived as a prompt to assess Mr. Geoffries. Any facial expressions and body language should be observed closely to understand the emotions he is attempting to communicate (Cotter & Evans, 2012, p 1). Some staff members were heard speaking to Mr Geoffries like he is a baby and also admonishing him. This is a form of psychological and emotional abuse and is associated with mental abuse to the patients being abused (Hoover R & Polson M, 2014, p 455). Harrigan (2010, p 21) supports this and argues that elder abuse is associated with distress and elevated mortality among the elderly as well as caregiver psychological morbidity. Therefore, it is of paramount importance to have the staff members mishandling the patient reported and have them directed on the significance of being emphatic to the patient and being professional during care delivery. It would also be important to investigate if the staff members are stressed or overworked because stress among caregivers is considered to be a contributing factor of abusive behavior in healthcare providers (Harrigan, 2010, p 21). Mr. Geoffries seems to be depressed. Depression can be because of boredom or loneliness (Poole, 2010, p 8). Therefore, managing behavioral disturbances and flexibility should be fundamental aspects of intervention for the patient. Therefore, it is important to structure the patient’s environment to prevent conditions that can cause disruptive behaviors. The environment can be improved by for instance controlling the temperature, facilitating activities and provision of stimulation and social contact (RCN, 2010, p 6). Staff members should also try to be flexible in adjusting the patient’s daily routine and environment based on his habits, impairment, identity and remaining abilities. Flexibility in mealtimes, food types, sleeping times and type of bathing can decrease disruptive behaviors in the patient (RCN, 2010, p 6). Music therapy can be considered for Mr. Geoffries. Music is important in reducing aggression in individuals with dementia, reduces anxiety, stimulates cognition, increases socialization, facilitates reality orientation and memory access and also enhances the quality of life in patients with dementia (Craig, 2014, p 12-13). Conclusion The paper presented case study of a patient with dementia. The patient had various predisposing factors to dementia that included old age, having diabetes mellitus, CVA, among other factors. The patient displayed various physical and psychosocial manifestations of dementia such as confusion, being aggressive, deterioration of activities of daily living etc. After being admitted to the home care, he develops urinary tract infection which is common in elderly patients with dementia. Treatment interventions for the patient included interaction with his family members and also pharmacological treatment for depression is being considered. Various pharmacological and nonpharmacological interventions have been suggested. This paper presents potentially useful management of patients with dementia patients and the recommended interventions merits further study. 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