Case Study Scenario
Edith, a 77-year-old lady presented to the emergency department (ED) via ambulance after falling in her home. On assessment Edith does not have any fall related injurie other than a minor graze on her left elbow.
Edith appears slightly confused and is asking for Margaret, her daughter. When contacted Margaret attends the ED department and informs staff that Edith’s local doctor recently identified Edith as recently been experiencing dementia, most probably due to Alzheimer’s disease. Margaret states that Edith does not appear more confused than normal. Given this the ED team do not suspect a potential alternative diagnosis of delirium.
Social History
Edith is a widow of five years, lives in her own home with minimal support from Margaret. Edith is relatively independent. She still drives a car, she self-regulates by not driving at night and only driving to her local shops, a friend’s house and her GP when needed. At the shops Edith pays for her groceries with larger notes as she seems unclear of how much to pass to the cashier. She became lost on the way home from the shops last week and was upset as she could not recognise where she was. After an hour she found her way home. Margaret gave her mother a mobile phone for just this type of emergency but Edith cannot understand which buttons to push and finds using the mobile phone frustrating. Margaret is worried that Edith may not be eating as well as she used to and at 48kgs, has lost 10kgs over the past 2 years. Margaret brings four or five frozen home cooked meals which she leaves in Edith’s freezer. Edith used to be a very good cook. She is famous for her elaborate birthday cakes. These days she has lost interest in cooking. Margaret visited Edith last week and found five meals still in Edith’s freezer. Edith has forgotten how to use the microwave and did not want to ask for help.
Edith has been more forgetful over recent months, misplacing her purse and car keys only to find them in the oven. Margaret says her mother is afraid someone will rob her so she sometimes puts her purse in odd paces them cannot find it. Edith arrives hours early for appointments and sometimes on the wrong date. Edith hides her inability to understand time by saying she likes to be early.
Edith is generally a social lady, visiting her friend twice a week at 10 am on Tuesdays and Fridays. Conversations are getting more difficult as Edith is slow to find the right word. Last week she drove to her friend at four in the morning thinking she might be late.
Medical History
AMI - 10 years ago, currency in rate controlled AF.
Bilateral cataract extraction and insertion of IOL’s – 8 years ago, required maintaining her driving licence.
Skin lesion on lower leg, dressed and healing –- 4 weeks – walked into her coffee table.
Medications
Apixaban 5mg BD (AF)
Rosuvastatin 20mg Daily (hypercholesterolaemia)
Centrum Advance 50+ for adults Multivitamin and mineral. Daily (general health , in particular Thiamine supplementation)
Paracetamol 1gram no more than 6hourly as needed.
End of Scenario
Answer the following seven (7) questions.
Use evidence based literature to support answers where appropriate.
All information not your own original thought must be referenced.
For each answer you must demonstrate person centred care by including reference to Edith’s circumstances where required.
Question 1
Edith requires a physical assessment in the ED. Provide evidence based person centred (ie Edith) rationales for each assessment provided below.
ECG
Respiratory Ax
Skin Ax
Mini cognitive assessment
Question 2
Edith has presented with dementia, most likely in the context of Alzheimer’s Disease.
List six 6 signs and symptoms of early Alzheimer’s disease which Edith is experiencing. For each sign and symptom provide detailed data from scenario to support your answer. Provide your answer in a table below. Do not apply your answer to the ED setting.
Question 3
The medical team perform further testing to rule out any potentially reversible cause of Edith’s dementia. Edith undergoes various tests to exclude other possible contributing pathology. The medical team send Edith for a brain perfusion scan, also called a SPECT (single-photon emission computerised topography).
These results confirm that a diagnosis of Alzheimer’s disease is most probably the cause of Edith’s dementia.
Why is it important for Edith and her family to have a definitive diagnosis? Use literature to support your discussion.
(suggest 100-150 words)
Question 4
Edith is transferred to the ward. The medical team commence Edith on an initial 4 weeks dose of 5mg BD of Donepezil (TN Aricept) with a view to monitoring Edith for effects and incrementally increasing the dose over time.
Explain to mode of action of Donepezil with respect to the pathophysiology of Alzheimer’s Disease?
(suggest 100-150 words)
Question 5
Alzheimer’s disease is associated with progressive memory loss. Outline why Edith is experiencing progressive memory loss.
(suggest 150-200 words)
Question 6 (divided into 2 parts in the rubric - Problem 1 and Problem 2) The following nursing problems are relevant for Edith:
1. Potential for decreased nutritional status impacting well-being and cognitive state and
2. Progressive impairment of memory and ability to live in her own home.
For each of the above nursing problems and provide five (5) relevant evidence based interventions for Edith that consider the specific clinical progression of Alzheimer’s Disease. Prioritise your interventions from 1(highest priority) to 5 (lower priority) for each problem. Justify your prioritisation with consideration of Edith situation
Include evidence based rationales for each intervention explaining why the interventions are specifically relevant for Edith who has Alzheimer’s Disease.
Answer may be supplied table format such as the example below.
(suggest 200-250 words per problem)
Problem 1
Problem 2
Question 7
Edith is still driving a car but admits she occasionally gets lost and is losing confidence.
What duty of care do the health care professionals have to Edith with respect to her driving a car now that she has a formal diagnosis of Alzheimer’s Disease? You may include reference to your State authorities eg. Police or Road authority.
(suggest 150-200 words) .
.