Assessing Diagnosing and Treating Dementia Essay Paper

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Assignment: Assessing, Diagnosing, and Treating Dementia, Delirium, and Depression

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With the prevalence of dementia, delirium, and depression in the growing geriatric population, you will likely care for elderly patients with these disorders. While many symptoms of dementia, delirium, and depression are similar, it is important that you are able to identify those that are different and properly diagnose patients. A diagnosis of one of these disorders is often difficult for patients and their families. In your role as an advanced practice nurse, you must help patients and their families manage the disorder by facilitating necessary treatments, assessments, and follow-up care.

To prepare:

Review the case study provided by your Instructor. Reflect on the way the patient presented in the case, including whether the patient might be presenting with dementia, delirium, or depression.
Reflect on the patient’s symptoms and aspects of disorders that may be present. What distinct symptoms or factors would lead you to a diagnosis of dementia, delirium, or depression?
Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results? How would you interpret and address the results of the Mini-Mental State Examination (MMSE)?
Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at

Assessing, Diagnosing, and Treating Dementia

Patient Information:

Initials: Mrs. P Age: 70 years Sex: Female Race: Caucasian

Subjective.

CC (Chief Complaint): Acute confusion, agitation, and restlessness.

HPI (History of Presenting Illness): The patient is a 70 year-old Caucasian female who presents with confusion, agitation, and restlessness in the absence of a history of head trauma. There is a positive history of dementia for which she is being treated with the selective acetylcholinesterase inhibitor donepezil (Aricept). The onset of the current exacerbation was two days prior to the clinic visit when the agitation and confusion became more pronounced. This being a decline in cognitive function, the location of the problem is the brain and the psyche. Currently, the symptoms are constant but previously they had been intermittent due to the medication. The confusion, agitation, and restlessness are characteristically acute and persistent. Aggravation of the symptoms occurs when the septuagenarian is put in unfamiliar surroundings; while relief occurs when in familiar surroundings such as her home with helpers and caretakers. The time that her symptoms are most noticeable is at night, but they can also occur at any time. On a scale of 1-10 the son describes the mother’s symptom severity as being at 7/10. Assessing Diagnosing and Treating Dementia Essay Paper

Current Medications: The patient is currently on a polypharmacy regime with the following medications for her dementia, hypertension, osteoporosis, diabetes, and chronic allergic rhinitis (Rosenthal & Burchum, 2018; Stahl, 2017):

Donepezil 10 mg orally every day
Metformin 500 mg orally twice daily
Hydrochlorothiazide (HCTZ) 50 mg orally every day
Glibenclamide (glyburide) 5 mg orally daily
Losartan (Cozaar) 50 mg orally daily
Alendronate (alendronic acid) 70 mg orally once every week
Multivitamin every day
Fish oil 1 tablet orally every day

Allergies: She is allergic to the drug atorvastatin, but has no history of any allergy to food products and environmental irritants.

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Past Medical history (PMHx): This patient has a significant medical history of comorbidities. The conditions are hypertension (well controlled), diabetes mellitus type II, osteoporosis, and chronic allergic rhinitis. For all these conditions he has been put on medications that she is currently taking. In her childhood she was completely immunized according to the pediatric immunization schedule of the time. As an adult, she has also received immunization such as the pneumococcal vaccine, the influenza vaccine, a Tdp booster vaccination, as well as two doses of the AstraZeneca Covid-19 vaccine.
Social History: The patient is a septuagenarian who lives with her son. Due to her condition, she really does not have any hobbies at the moment. She however enjoys being with her son and the company of her grandchildren. They live on the ground floor of their apartment complex and she is therefore not at any particular risk of falls from using the stairs. The air quality is good and their area of residence is well served with hospitals and clinics including mental health clinics. When out in public, she always wears a face mask against Covid-19 even though she has been fully vaccinated.

Family History: According to the son of the patient who served as her historian, there is no significant history of mental illness within the immediate and extended family. Life expectancy is however high in the family but none of the other known relatives who have reached 70 years and above has been known to suffer psychiatric problems. She has an only son and three grandchildren. Assessing Diagnosing and Treating Dementia Essay Paper

Review of Systems (ROS):

General: She denies any fever, weight loss, chills, or fatigue.

HEENT: There is a repudiation of having any type of migraine or headache. She claims that she does not have double eyesight, squint, or sensitivity to light. She also says he has not had any tearing in her eyes. She has not seen an ophthalmologist in about one year and has never used eyeglasses. Sneezing, loss of smell, a runny nose, inflammation of the nasal cavities, and nose bleeding are not among her symptoms. She claims to be free from ear discharge, loss of hearing, and tinnitus. She says she is not wearing any cochlear implants right now. She also denies any bleeding from the gums or having any type of oral ulcers. She does not have any sore throat or dysphagia. Lastly, she also not visited an ENT expert in over two years now.

Skin: She denies dermatitis, any form of rashes, or itching.

Cardiovascular: She is negative for palpitations, any chest pains or chest tightness, and has also not had pedal edema or shortness of breath while laying supine at night. There is also no back pain.

Respiratory: Negative for shortness of breath, coughing, wheezing, or hemoptysis. Also denies breathlessness on exertion.

Gastrointestinal: Negative for vomiting, diarrhea, or nausea. Also denies irregular bowel movements with the latest bowel action reported as being the morning of the visit.

Genitourinary: Denies pain on micturition, bladder incontinence, or difficulty urinating.

Neurological: Reports a positive history of cognitive impairment with loss of memory, disorientation, and agitation. She denies any history of falls or traumatic head injury.

Psychiatric: The patient’s son describes a gradual loss of memory as well as a loss of consciousness of time, place, and the surroundings. She cannot tell what date it is or where she is most of the time, even in her own home. She also has no recollection of where she put things like the dentures even just moments ago. These difficulties, according to her son, have negatively impacted her ability to function in daily tasks and social situations.

Musculoskeletal: Reports joint stiffness, arthralgia, and bone pain. Also denies any history of a fracture.

Hematologic: Negative for clotting or any other blood disorders.

Lymphatics: Denies ever having a splenectomy and currently negative for lymphadenopathy of any region.

Endocrinologic: Does not have excessive thirst or excessive drinking of water. She is also negative for heat and cold intolerance as well as excessive sweatiness. She has never been on any kind of hormonal therapy. Assessing Diagnosing and Treating Dementia Essay Paper

Objective:

Physical exam:

General: The patient is disoriented in time, space, person, and situation. She is however dressed appropriately for the time of the day and the weather.

Vital signs: BP 120/64 mmHg normal cuff and sitting; P 72 regular; T 98.1°F; RR 20 non-labored.

HEENT: PERRLA: Both of the patient’s pupils are equal, round, and reacting equally to light and accommodation. EOMI: Her extraocular muscles are intact and functioning. The nasal septum is intact with absent hypertrophy of the turbinates. There is no rhinorrhea or otorrhea and external auditory structures like the tragus and pinna are non-tender and symmetrical. Internally, the tympanic membranes are not ruptured on either side and they show a light reflex that is adequate. The buccal cavity shows no signs of ulceration and the gums also have no gingivitis or signs of bleeding. There is no exudate or erythema in te throat.

Respiratory: The patient’s lungs are clear on auscultation with no crepitations, wheezing, rhonchi, crackles or rales.

Cardiovascular: The two heart sounds S1 and S2 are audible and regular in both rate and rhythm. There is no evidence of a rub, a gallop, or a murmur. Edema (pedal and generalized) is also absent.

Diagnostic results:

The plain chest X-ray showed no adverse cardiopulmonary findings.
A CT scan of the head revealed evidence of diffuse cerebral atrophy.

Assessment:

Differential Diagnoses

Dementia

Based on the patient’s condition and age, this is perhaps the most likely diagnosis. It is therefore the primary diagnosis, and the rationale for this is that the patient’s complaints match the requirements for dementia in the DSM-5 (Sadock et al., 2015; APA, 2013). The following are the DSM-5 dementia diagnostic criteria:

There is confirmation of cognitive decline in present complaints when contrasted with earlier symptoms. Speech, recall, perception, learning, and social cognition are among the aspects of cognition that are impacted. This proof is defined by the following sources:
Anxiety from the patient about the onset of symptoms, concern from a member of the family or someone who knows the patient, or concern from a professional who evaluates the patient. In any one of these instances the people involved will tell you that there has been a significant deterioration in cognitive performance in the patient.
Deterioration in cognitive function that has been clinically documented and archived by a qualified mental health professional.
The patient’s mental disability prevents them from being self-sufficient in their everyday tasks, such as activities of daily living (ADLs). Activities such as bathing and eating are included in these ADLs.
Cognitive impairments do not always arise in the context of delirium.
The cognitive impairment is not caused by some other mental illness, such as schizophrenia or depression.
Normal Cognition

Normal cognition is the other differential diagnosis to dementia (Sadock et al., 2015; APA, 2013). As per the DSM-5, there is a lot of overlap between this particular differential diagnosis and dementia that the diagnostic boundaries are very thin. As a consequence, distinguishing between the two is difficult and requires both practice and experience. This is due to the similarity in symptoms between normal cognition and the major diagnosis in this case (Dementia). If one is to comprehend the distinct qualities of the two, it is advised that they perform a rigorous comprehensive psychiatric evaluation (Sadock et al., 2015; APA, 2013).

Persistent Delirium

After dementia and normal cognition, this is the third most common diagnosis, according to the American Psychological Association (APA, 2013). It’s difficult to tell the difference between it and the primary diagnosis, and the two conditions might coexist in the same individual. A detailed assessment of arousal and attention span is required to make the distinction. Delirium symptoms appear suddenly, which is a significant distinguishing feature. The signs of dementia are usually subtle and appear slowly over time. The loss in cognition may be tracked and observed to be gradual. The distinction between the two is that delirium is marked by inattention (Sadock et al., 2015; APA, 2013).

Mini-Mental Status Examination (MMSE)

The patient shows disorientation in time and place even though she is alert. Her speech is clear, coherent, and goal-oriented even though it veers off and becomes tangential occasionally. She has no abnormal tics and gestures. Hallucinations, delusions, and homicidal ideation, and suicidal ideation are all absent. The score for this test remains as in the previous one at 18/30. What this means is that she still has moderate dementia as a neurocognitive disorder (NCD).

Plan:

The treatment plan for this patient will involve the following:

Continue with donepezil (Aricept)
Striking out glibenclamide or metformin and replacing them with just one antidiabetic that is effective. This is to try and correct the polypharmacy because the patient is aged and at risk of toxicity. Toxicity is known to cause delirium especially in aged patients already suffering from dementia such as this one.
Family therapy for her and the son.
Referral to a speech therapist.
Repeat MMSE tests during the return follow-up visit after four weeks.
Health education on the importance of compliance with treatment. This will require that the patient be given a caregiver who will give her the due medication at the correct time and dose.

Reflection:

I would not change anything about how I assessed and treated this patient if I had to do it all over again. This is due to the fact that I evaluated the client in a systematic manner, commencing with the collecting of subjective data. I next went about gathering objective data, such as a physical examination and diagnostic tests to rule out other medical and mental disorders (Ball et al., 2019; Bickley, 2017). While doing so, I conducted another mini-mental status examination, or MMSE, to determine the extent of the cognitive decline. Following that, the assessment was completed by generating three differential diagnoses based on probability. I sought informed consent through the son before any procedures and guaranteed confidentiality at all times.

Conclusion

Dementia is one of the neurocognitive disorders (NCDs) within the same diagnostic family in the DSM-5. It is defined by cognitive impairment in domains such as recollection or memory, speech, and learning. Various psychometric tests such as the MMSE and the Geriatric Depression Scale (GDS) can be used to determine the extent of the dementia and evaluate progress. Treatment is pharmacotherapeutic, psychotherapeutic, and supportive. Assessing Diagnosing and Treating Dementia Essay Paper

Subjective.

CC (Chief Complaint): Acute confusion, agitation, and restlessness.

Donepezil 10 mg orally every day
Metformin 500 mg orally twice daily
Hydrochlorothiazide (HCTZ) 50 mg orally every day
Glibenclamide (glyburide) 5 mg orally daily
Losartan (Cozaar) 50 mg orally daily
Alendronate (alendronic acid) 70 mg orally once every week
Multivitamin every day
Fish oil 1 tablet orally every day