Mental Health Emergencies - Essay Example

?Responding to a Mental Health Emergency Involving the Elderly Case Scenario: You have been called at 11.30 to a 72 year old female who lives with her husband. The husband has called the ambulance because his wife is starting to turn the gas oven on and off and insisting that she needs to sit in front of it to keep warm. He is distressed that she seems not to recognise him and she keeps mumbling to the oven. On arrival you see that she is pale and is still in her nightie. She tries to get to her feet but does not appear to be able to get herself up from her chair. Introduction Supporting the elderly is becoming more challenging in these contemporary times. The more they insist on their independence, the more they become at risk of danger due to their limitations from their advanced age. This case analysis will illustrate how some odd behaviors exhibited by an elderly woman can indicate symptoms of a mental disorder and how she can be helped. It will show how mental health assessment is done and the corresponding care and treatment interventions for the mentally ill patient. For the case at hand, an elderly 72 year old woman was reported to keep turning the gas oven on and off reasoning that it kept her warm. Her husband was worried about this unusual behavior of his wife and the fact that she did not seem to recognize him. Upon arrival at their residence, the old lady was pale and still in her nightie and could not get up from where she was sitting. Seeing the old lady like that, apparently not behaving as she may normally do, the husband may be asked probing questions regarding her behaviors. Like when did she start behaving oddly and what does she do? Has she exhibited episodic memory impairment? Does she manifest any pain, and if she does, which part of her body? Her health history may be discussed, taking note of serious illnesses and hospitalizations. Her family and social history may likewise be discussed. In getting the whole history of her life, a provisional diagnosis may be made with the help of the Diagnostic and Statistical Manual of Mental Disorders (DSM 4th Edition, TR) and upon consultation with the National Institute of Neurological Communicative Disorders and Stroke (NINCDS) and the Alzheimer Disease and Related Disorders Association Criteria (ADRDA) From the initial observation of the old lady not recognizing her husband and the behaviors that show disturbances in her executive functioning such as mumbling to the oven, inability to care for self, as she was not yet dressed considering it was already almost noon, and her difficulty in standing up, it may be possibly Alzheimer’s Disease. This diagnosis may be validated by evidences of her memory impairment and a decline in her cognitive functions as well as her social and occupational functioning. Such cognitive deficits are not due to central nervous system, systemic, or substance-induced conditions and she does not have any other psychiatric disorders (Medical Criteria.com, 2007). One cannot just label her as having Alzheimer’s Disease until a complete and thorough mental health assessment is done which includes both biological, social and psychological evaluation of the patient as well as accounts of the people close to her. In order to facilitate diagnosis, it would be very helpful to learn about Alzheimer’s Disease (AD) so that information on symptoms, etiology and treatment may be known and compared to the old lady’s symptoms. Gently coaxing the old lady to come to the hospital for evaluation should be done with the support of her husband. She may not want to be physically touched by strangers, so it would help if her husband, whom she may not recognize but whom may be more familiar to her than the health practitioners taking her, will hold her and accompany her to the hospital or health facility doing the diagnosis. Discussion Trends e-Magazine (2012) describes AD as the degeneration of the nervous system which eventually leads to dementia. It is an incurable and progressive neurodegenerative disease which affects adults, usually those who are 60 years old and above. This most common form of dementia ultimately destroys memory and thinking skills that even the simplest of tasks become impossible for the affected individual to do (Singh et al, 2011). The World Health Organization (WHO) estimates that currently, 5% of men and 6% of women over sixty years are afflicted by Alzheimer’s type of dementia. 35.6 million people currently have dementia and will increase to 65.7 million by the year 2030 and further increase to 115.4 million by 2050 (Wimo & Prince, 2010). Possible Causes Neurodegenerative disorders like AD may be caused by toxic chemicals or xenobiotics from pesticides, herbicides and other chemicals in the production of food which produce neurotoxins affecting the order of transmission of chemical signals between neurons in the nervous system (Singh, et al., 2011). Lifestyle factors also contribute to the development of this disease such as low education, smoking, physical inactivity, depression, mid-life hypertension, diabetes, and mid-life obesity (Barnes & Yaffe, 2011). Pocnet et al (2011) report that AD is one of the leading causes of cognitive decline in old age which is accompanied by personality changes. This means that there is an obvious shift in the demeanor of the individual, like from someone with a naturally jolly and affectionate personality, the individual suddenly turns to be cold and unemotional towards others. Biologically, Rauk (2009) explains that the massive loss of neurons of the individual affected by Alzheimer’s also impacts the signaling between cells, thus, transmission of information is disrupted. When the individual dies, there are tangles inside and senile plaques outside the cells in the brain. The major component of such plaques is a small 40- or 42- amino acid peptide called amyloid beta (A?). This substance has been identified as the causative agent in Alzheimer’s (Singh et al., 2011). With the presence of these peptides in the brain, it is no wonder that the individual becomes highly dysfunctional. Progression Singh et al (2011) enumerate the seven stages in the progression of Alzheimer’s disease. The first stage is the normal behavior of the individual. The second stage finds the individual with minor memory lapses. He or she forgets some details or things to bring. The third stage is where confusion and loss of names becomes more and more frequent. Because this is very common with older people, it does not necessarily lead to Alzheimer’s disease. The fourth stage is characterized by the inability to think rationally and is considered to be “mild” Alzheimer’s. If this progresses to the next stage (stage five), the individual is already unable to remember the names of close relatives. This is considered “moderate” Alzheimer’s. Further down the line is stage six, the “moderately” severe” Alzheimer’s wherein the individual is unable to care for oneself and his personal needs. Loss of speech and incontinence happens in the next stage (stage seven). This is when the individual is like a human vegetable unable to do anything productive and eventually leads to the individual’s death (Alzheimer Society of Canada, 2008). Diagnosis The NINDS-ADRDA Diagnostic Criteria for Alzheimer’s Disease checks for probable AD when the following core criteria are met: A. The individual presents some early episodic memory lapses together with the following: 1. There is a gradual change in the individual’s memory function in the last six months or more. 2. Individual has recall deficits which do not improve even if there is cueing or recognition testing and after the effective encoding of information has already been controlled, meaning the individual has significantly impaired episodic memory on testing. 3. The episodic memory impairment can be isolated or associated with other cognitive changes at the onset of AD or as AD advances (Firman, 2009, para 1) These symptoms should be accompanied by one or more of the following supportive features which are more biological in nature as enumerated in Firman (2009): Medial temporal lobe atrophy Abnormal cerebrospinal fluid biomarker Specific pattern on functional neuroimaging with PET Proven AD autosomal dominant mutation within the immediate family Other observable symptoms include gait disturbances, seizures, behavioral changes, difficulty in seeing clearly due to visual field deficits, sensory loss, and depression (Firman, 2009). DSM-IV-TR’s criteria for Alzheimer’s Disease on the other hand, enumerates the following: 1. The individual develops several cognitive deficits as manifested by both memory impairment and one of or more of the following conditions: Aphasia; Apraxia; Agnosia; and disturbances in executive functioning 2. The cognitive deficits result from a decline in the individual’s previous functioning and consequently, cause social or occupational impairments. 3. There is no improvement in the course of the cognitive impairment . There is gradual onset and continuous decline. 4. The cognitive deficits are not due to other central nervous system, systemic, or substance-induced conditions which may cause progressive impairments in memory and cognition. 5. There is no other psychiatric disorder affecting the cognitive impairment. (Firman, 2009) Early Detection As with any other disease, early detection will most likely lower the chances of the development and progression of the disease especially for those who are at high risk. However, for Alzheimer’s, detection is left to signs and symptoms that are keenly observed by the individual’s loved ones because some changes in behaviors are easily attributed to aging. Trends e-Magazine (2012) recently reported two different approaches for early detection of the physical manifestations of Alzheimer’s. One is from the University of Medicine and Dentistry of New Jersey and the Northwestern University in Ilinois. Their findings link diabetes to the onset of AD. They discovered that there was a substantial increase in amyloid beta peptides in the brain cortex and hippocampus when an individual has diabetes (Kasinathan et al., 2012). Apart from the assembly of amyloid beta “oligomers”, insulin has likewise been identified as having a role in the development of AD. Insulin plays an important part in the formation of memories. The researchers found that the oligomers impair memory formation by causing the elimination of insulin receptors from the surface membranes of the brain. Trends e-Magazine (2012) explains that a vicious cycle begins wherein the brain becomes insulin-resistant while the diabetes contributes to more oligomer accumulation. The neurons become more insulin-resistant, hence it is the memory formation that suffers. The researchers found that it is minimally invasive to test for amyloid beta pathology by checking the retinas of individuals suspected of having AD since this part of the eye is considered an “extension of the brain” (Trends e-Magazine, p. 29). Another breakthrough in the early detection of possible AD was found by researchers from the Instituto de Estructura de la Materia in Madrid. The technique analyzes fluid around the brain and spinal cord for levels of amyloid-beta peptide through infrared spectroscopy. This measures infrared radiation emitted or absorbed by white blood cells, and different stages of formation of the peptide in the blood cells result in different stages of AD. Treatment Interventions Once an individual is diagnosed with AD, treatment interventions need to be planned out and implemented. Current developments have been positive and hopeful. One of this is the development of prescription drugs (Bullock, 2001). Oddo et al. (2010) report a treatment using a protein called CBP which restores the damage done by the accumulation of the amyloid protein. Another effect of this protein is the triggering of the production of other proteins necessary for memory creation. Still another treatment recently discovered at the Northwestern University Feinberg School of Medicine is the use of a therapy drug that was also found to treat Parkinson’s disease, Multiple Sclerosis and Traumatic Brain Injury which share the same symptom with AD, which is neuroinflammation. It is a drug that binds to and decreases cytokine molecules which attack the brain and causes synapses to misfire. When cytokine attacks, connections between neurons are lost, damaging the cortex and hippocampus directly affecting memory and decision making abilities of the individual (Watterson, 2012). For this drug to work with Alzheimer’s patients, it should be administered before the disease has reached its late stage. Dr. Pasinetti of the Mount Sinai School of Medicine in New York also recommends the use of immunoglobulin to keep synapses flexible. This doctor claims that immunoglobulin protects Alzheimer’s patients from memory loss and other symptoms of the disease (Trends e-Magazine, 2012). Aside from these newly-developed drugs, herbal remedies have also been discovered in slowing down the brains degeneration (Singh et al., 2011). These herbal medicines have been found to be as effective as prescription drugs and have fewer side effects. Some examples of these herbal medicines are Ginkgo Biloba, Galanthus Caucasicus, Huperzia Serrata, among others. Conclusion Alzheimer’s Disease is getting to be a serious health problem being the sixth leading cause of death in the United States (Trends e-Magazine, 2012). Usually, it takes eight years for an afflicted individual to suffer the disease until death finally claims him, so it is not only him who suffers but also his loved ones who care for him and feel the frustration of seeing him slowly slipping away to the extinction of his memory. Hopefully, the old lady in this case will respond well to the medicines recommended for treatment if she is confirmed for AD. In its early stages, it would be good to keep her mind well-stimulated with activities that deal with cognitive skills such as doing crossword puzzles, engaging in stories about her life, participating in games such as Bingo and other memory-enhancing activities. It would also greatly help if she is provided with enough social and emotional support by her loved ones by keeping her feeling loved and valued. As long as she lives, it is important to provide her with the care and understanding that she deserves, as it is predicted that once Alzheimer’s sets in it will only deteriorate until she loses all her memory. It will be a heartbreaking experience for her loved ones whom she will not recognize, or worse, exist as a human vegetable – physically alive but spiritually dead. That is why, from the time she is diagnosed to have AD, her family already needs to prepare themselves for what is to come so they are all ready to face the challenges that will be coming their way. References Alzheimer Society of Canada (2008) The Progression of Alzheimer's disease— Overview; Early Stage; Middle Stage; Late Stage; and End of Life information sheets. Barnes, D.E. & Yaffe, K. (2011) The Projected Effect of Risk Factor Reduction on Alzheimer's Disease Prevalence, The Lancet Neurology, September, 2011 issue Bullock, R. (2001) Drug treatment in dementia. Curr Opin Psychiatry Vol.14: 349-353. Firman, G. (2009) Diagnostic Criteria for Alzheimer's Disease (AD), Medical Criteria.com, Retrieved on 10 October 2012 from http://www.medicalcriteria.com/site/index.php?option=com_content&view=article&id=52%3Aneuroalzheimer&catid=76%3Apsychiatry&Itemid=80&lang=en Kasinathan, C., Klein, W. & Frederikse, P. (2012) Amyloid-? and Tau Pathology of Alzheimer's Disease Induced by Diabetes in an Animal Model, Journal Of Alzheimer's Disease, Vol, 31, No. 2, Oddo, S. et al. (2010) "CBP Gene Transfer Increases BDNF Levels and Ameliorates Learning and Memory Deficits in a Mouse Model of Alzheimer's Disease," Proceedings Of The National Academy Of Sciences, December 28, 2010 Pocnet, C., Rossier, J., Antonietti, J.P. & von Gunten, A. (2011) Personality Changes in Patients With Beginning Alzheimer Disease, The Canadian Journal of Psychiatry, Vol 56, No. 7 Rauk A. (2009) The chemistry of Alzheimer s disease. Chemical Society Review, 38:2698-2715. Singh, N., Pandey, B.R., Verma, P. (2011) An Overview of Phytotherapeutic Approach in Prevention and Treatment of Alzheimer’s Syndrome & Dementia, International Journal of Pharmaceutical Sciences and Drug Research 3(3): 162-172 Trends E-Magazine, (2012) Hope for the Victims of Alzheimer’s Disease, Trends E- Magazine, September 2012 Issue Watterson, M. et. al (2012) Early Stage Drug Treatment that Normalizes Proinflammatory Cytokine Production Attenuates Synaptic Dysfunction in a Mouse Model that Exhibits Age-Dependent Progression of Alzheimer's Disease-Related Pathology, The Journal Of Neuroscience, July 25, 2012, Wimo, A., Prince M. (2010) The Global Economic Impact of Dementia, Alzheimer’s disease International, World Alzheimer Report, 2010. Read More