Cognitive decline and functional impairment case study

QUESTION

Part One

The client is a 75-year-old female and was brought by her family to an assisted living facility.  Over the previous year, she had increasing difficulty taking care of herself at home. The family reported the following problems prior to making the decision to place the client: leaving a stove burner turned on long after she stopped cooking, putting household objects away in unusual places (frying pan in the dryer), and leaving the house dressed inappropriately for the weather.  The family also noticed that medication bottles were in a state of disarray, and she could not give them a coherent account of which medications she was taking or on what schedule.  The family presented the medication bottles to the admitting nurse.

Acetylsalicylic acid (ASA) EC 81 mg one tablet p.o. daily

Amiodarone (Cordarone) 200 mg two tablets p.o. daily

Diazepam (Valium) 2 mg one tablet p.o. twice a day

1. Share your observations on this situation.
2. Provide examples of some statements to elicit additional information you would like to know for your assessment.
3. What assessment tools would be useful?

A few days after the client moved to assisted living, staff members noticed that she was developing increasing symptoms of anxiety.  These included physiological symptoms such as elevated vital signs, hyperventilation, and diaphoresis; behavioral signs of pacing and an inability to relax, and cognitive symptoms such as catastrophic thinking.  However, she was not able to specify any cause for the anxiety.  It appeared to be an adjustment disorder related to moving to the facility.

1. Discuss physiological adjustments a new resident may experience.
2. What dietary considerations may be influencing the client’s adjustment?
3. What behavioral interventions may be beneficial for a client making this transition?

Part Two

The psychiatric nurse practitioner interviewed the client and reviewed her medications. The PMHNP found that the client’s primary care physician had been prescribing diazepam (Valium) for her for at least five years prior to admission. In gathering collateral information, family divulges that the client has taken larger doses of diazepam than prescribed for some time.  Rather than the prescribed 2 mg twice a day, client has often taken 2 mg up to 4-6 times per day.

1. How would you adjust the medications to address the client’s symptoms?  Be specific in your recommendations.
2. Discuss the impact of substance use/abuse on the elderly as baby boomers age.  How will this influence care from providers?

Part Three

The client has successfully adjusted to the prescribed medication dosages and is adapting to her new living arrangements.  She attends scheduled, supervised outings with staff and peers and functions well.  The client has been pushing to move home.  Her family is pleased with her progress and expresses feelings of guilt for perhaps prematurely placing the client in assisted living. They are considering moving her back into her home, as they are recognizing the financial impact of 24-hour care.  They believe they can extend her finances and assist with medication administration while checking on her twice a day.

1. How would you respond to the family’s consideration? What recommendations might you make?
2. What are your feelings about this case and this patient? Share your “personal” feelings/thoughts about treating a patient with these circumstances.  This is more of a reflection or introspective statement.

ANSWER

Part One

Observations

The client, a 75-year-old female, has been exhibiting signs of cognitive decline and functional impairment, which led to the family’s decision to place her in an assisted living facility. The reported problems, such as leaving the stove burner on, misplacing objects, and dressing inappropriately, indicate difficulties with memory, attention, and problem-solving. Additionally, the disarray of medication bottles and the client’s inability to provide accurate information about her medications suggest impaired medication management and potential medication-related risks.

Statements to Elicit Additional Information

“Can you tell me more about the instances where you left the stove burner on or put objects in unusual places?”
“Could you describe any changes you’ve noticed in your memory or ability to remember important things?”
“Do you have any difficulties managing your medications? Can you explain your current medication regimen and schedule?”

Assessment Tools

Mini-Mental State Examination (MMSE): A brief cognitive screening tool that assesses orientation, memory, attention, and language skills.
Geriatric Depression Scale (GDS): Assesses depressive symptoms, which can contribute to cognitive and functional impairments.
Medication reconciliation: A process of reviewing and comparing the client’s current medication regimen with previous prescriptions to ensure accuracy and identify any discrepancies or concerns.

Physiological Adjustments for a New Resident

Adjusting to a new living environment can induce stress and anxiety, leading to physiological responses such as elevated vital signs, hyperventilation, and diaphoresis. These symptoms may arise due to the unfamiliar surroundings, changes in routine, and the need to adapt to new social interactions and support systems.

Dietary Considerations

Changes in diet or eating patterns can influence a client’s adjustment. In this case, it is essential to assess the client’s nutritional status, dietary preferences, and any specific dietary restrictions. Addressing these considerations can support physical well-being and promote a sense of familiarity and comfort for the client.

Behavioral Interventions

To assist the client in transitioning to the assisted living facility, the following behavioral interventions may be beneficial:
Social support: Encouraging the client to engage in supervised outings and interact with staff and peers can foster a sense of belonging and decrease feelings of isolation.
Relaxation techniques: Teaching the client relaxation exercises, deep breathing, or mindfulness techniques can help manage anxiety symptoms and promote a sense of calm.
Structured routines: Establishing predictable daily routines and providing clear instructions can help reduce anxiety and provide a sense of stability for the client.
Psychoeducation: Educating the client and family about the adjustment process and the support available in the assisted living facility can alleviate concerns and increase their understanding of the benefits of the new living arrangements.

Part Two

Medication Adjustment

Considering the client’s misuse of diazepam, it would be necessary to address the potential dependence and withdrawal effects associated with long-term use. A gradual tapering of the diazepam dosage, under close supervision, would be recommended to minimize withdrawal symptoms and mitigate the risk of rebound anxiety. Non-pharmacological interventions, such as cognitive-behavioral therapy or relaxation techniques, may be beneficial in managing anxiety symptoms during the tapering process.

Impact of Substance Use/Abuse on the Elderly

As the baby boomer generation ages, substance use and abuse among the elderly can pose significant challenges for healthcare providers. Older adults may be more vulnerable to the adverse effects of substances due to age-related physiological changes, comorbidities, and polypharmacy. Substance abuse can increase the risk of falls, cognitive impairment, medication interactions, and exacerbation of underlying medical conditions. Healthcare providers need to be vigilant in screening, identifying, and addressing substance use issues among elderly patients to ensure safe and effective care.

Part Three

Response to Family Consideration

While acknowledging the family’s desire to accommodate the client’s wish to move back home, it is essential to consider the client’s overall well-being and safety. Moving the client back home may compromise her access to 24-hour care and support, potentially leading to an increased risk of accidents, inadequate medication management, and social isolation. Instead, a collaborative approach can be taken, where the family’s involvement in the client’s care is optimized within the assisted living facility. This may include regular visits, participation in care planning meetings, and assistance with medication administration, thus ensuring the client’s safety and overall care needs are met.

Personal Reflection

Treating a patient with circumstances similar to this case can evoke a range of emotions and thoughts. It is disheartening to witness the decline in cognitive and functional abilities, as well as the challenges faced by both the client and her family. However, it also presents an opportunity to provide compassionate care, support, and interventions that can enhance the client’s quality of life and promote her well-being. Collaborating with the interdisciplinary team and involving the family in the care process can help optimize the client’s outcomes and provide a sense of reassurance to the family. Being able to make a positive impact on the client’s journey through the aging process is rewarding and reinforces the importance of person-centered care for older adults.