ER is an 84-year-old female with acute mental status change. She is lethargic but is alert to self, not oriented to time, or place. ER lives in a nursing facility and was brought in by EMS to the emergency room for altered mental status times two days. She was seeing approximately one week ago for lethargy but was returned to the facility after IV fluid rehydration. Approximately two days ago she started acting very lethargic, not participating in activities, and decreases eating at mealtime. Upon transfer, to the hospital, she was evaluated with a CBC, urinary analysis and culture, and a chest x-ray. The reason for the chest x-ray was to rule out pneumonia Because she had a cough that was persistent but not productive for the last week. For many older adults’ simple illnesses do not present is if they did when we were younger. As we age, symptoms become difficult to distinguish, and or masked, or present vaguely (Wilson ; Markland, 2014). The older population is more prone to urinary tract infection than any other population. As we get older, our immune system gets weaker and went this week and then accompanied by muscles that are losing their strength in the bladder can increase the occurrence of urinary tract infections. When her CBC and chest x-ray or evaluated their findings were negative. When the results of her urinalysis and culture came back, it was positive for urinary tract infection. According to Flaherty and Resnick (2014), elderly individuals who have minimal or cognitive impairment find it challenging to verbalize pain or discomfort, and it is suggested to not prescribe opiates or pain medications due to mental impairment.
After evaluation and lab and diagnostics it was determined that the primary diagnosis and cause her for her acute delirium was related to her acute urinary tract infection. According to Rowe ; Juthani-Mehti (2013) distinguishing characteristic symptoms from a urinary tract infection and asymptomatic symptoms of bacteriuria is a difficult task for the clinicians and one bust use focus on treatment and no to overprescribe antibiotics when unsure of diagnosis initially. ER was found to have a urinary tract infection and was prescribed nitrofurantoin 100mg twice a day for ten days. ER was evaluated approximately 48 hours after initiation of antibiotic treatment, and she had returned to baseline. ER was able to relate to this clinician that she did not feel right and was not able to understand why she felt the way she did. This clinician learned that you must look deeper past simple symptoms to accurately treat your patients not just symptoms.
Dementia is a progressive and challenging disease that affects the elderly but can occur earlier in an individual’s life. The patient for the journal this week who is diagnosed early with dementia at the age of 47. The initial signs of dementia might be as simple as forgetting things, concentration issues, or merely a struggle forgetting words that would typically come easily to express themselves. For many frail elders, dementia impacts how he or she will live there remaining years. It impacts how they will care for themselves, clean themselves, or merely the inability to live alone anymore. There are many forms of dementia that affect many individuals such as; Alzheimer’s disease, Frontotemporal dementia, Huntington’s, Parkinson’s disease, dementia with Lewy bodies, vascular dementia, these are only a few there are many more forms that affect individuals (Alzheimers Association, n.d.). TW is an African-American female approximately 76 years old. Being diagnosed early has been difficult for a for filling life because the diseases progressed over the last 25 years. TW has lived in a facility for the last ten years due to the inability of her family to care for her. The Progression of her disease has led her to the end stage of Alzheimer’s. TW is no longer able to dress, shower, feed, or even communicate in full sentences. TW has no family, so the Nursing home has become her family and watch the progression of her disease over the last ten years. The facility that TW lives in Uses the mini-mental state exam to assess their patients quarterly to evaluate their impairment. TW is the last assessment was 10. According to TW’s facility, she is down approximately three points since last year. This point decline is an indicator of the progression of Alzheimer’s disease. Baseline evaluation aids facilities to establish a decrease in cognitive function along with ADLs. TW currently takes no medications for dementia she only takes medications for anxiety which is Xanax 0.25 mg TID. Many physicians and clinicians utilize the use of cholinesterase inhibitors and N-methyl-D-aspartate (NMDA) receptor antagonist in the early course of the patient’s treatment when mild symptoms are present. NMDA’s are used to slow the progression of the illness and to delay impairment in the patient for as long as possible (Robinson, Tang, & Taylor, 2015). TW over the last six months has been experiencing more episodes of confusion, forgetfulness, and the inability to do simple tasks. When interviewed she has no complaints. TW is now finding it more difficult to move around and spends most of her time in a chair or bed. Her conversations have become limited with the use of words that she uses, and it has come to the use of one-word answers. TW has also started to lose weight, and her physical appearance is becoming cachectic. Her provider has indicated that her Mini-Mental State Exam (MMSE) is at the severe or end-stage Alzheimer’s disease end it will only progress further. Caring for TW will require CBC checks to a evaluate electrolyte balance due to decreased oral intake, and she could become dehydrated. At this time the plan is to treat the patient’s symptoms and develop a plan of care that will make TW comfortable until she still comes to her illness. TW did have an advance directive and indicated she did not want any artificial feeding measures at end-of-life. So, the goals of care for TW will be to provide comfort measures. Caring for individuals at end-stage Alzheimer’s disease can be difficult and can cause stress on the caregivers and family. In TW ‘s case, she knew that eventually she would lose function and would not be able to feed or bathe herself and took steps so that her wishes would be honored, and she would not receive artificial nutrition. For many others with advanced or end-stage Alzheimer’s disease, this is not an easy decision and families choose to go an artificial nutrition route. For clinicians this can be a stressful time because family and feelings get involved and placing a peg tube and using artificial nutrition can cause more harm than good. There is presently no data to support that supports artificial nutrition will aid in the quality of life of the person with Alzheimer’s (Smith & Ferguson, 2017). This will be a debate and an issue for many years to come. For this student is learning how to advocate for their patient but how to work with families and patients of this debilitating disease will be a continual lesson. This student learns that being compassionate and a good listener will provide your patient with the care that they need.