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Case Study: Mrs. Allen – an Alzheimer’s dementia caregiver Author: Olimpia Paun, PhD, PMHCNS-BC, Rush University College of Nursing, Chicago, IL.

Overview: Mary Allen is a 70-year-old African American woman who appears her stated age and is very engaging in conversation. She reports that she stayed home to raise the eight children she had with Mr. Allen. After all children grew up, Mrs. Allen worked as a certified nursing assistant in a long-term care facility near her home. She retired a few years ago, around the time her husband started to show the first signs of Alzheimer’s disease. They live in the house they have owned since getting married and share it with one of their daughters and her two teenage sons. Mrs. Allen is a devout Baptist and is actively involved with her faith community as a volunteer. In addition to his newly diagnosed Alzheimer’s disease, her husband has a history of stroke, prostate cancer, and hypertension. Mrs. Allen has no history of chronic illness, but was recently diagnosed with elevated blood pressure (140/80). Currently, she is reluctant to take antihypertensive medication, but is deliberate in making dietary (low fat, low sodium) and physical activity (walking with a group of women 2-3 times a week) changes. Monologue: During her weekly home visits to manage Mr. Allen’s chronic conditions, the visiting nurse (case manager) sets aside time to talk with Mrs. Allen and to answer her questions. Mrs. Allen shares her own experiences in taking care of patients with Alzheimer’s dementia and acknowledges that it is different taking care of “your own”. Simulation Scenario 1 occurs in the Allen home during a regularly scheduled home visit by a nurse who is following up on Mr. Allen’s adjustment to newly prescribed medication and assessment of his

a month later. Allen’s recent pattern of insomnia and weight loss coupled with her comment: “I have a lot on my mind and in my heart” indicate that she may be experiencing depressive symptoms related to her husband’s gradual deterioration and the caregiving situation overall. Allen and her daughter and finds out that she and her sons are consistently participating in the care of Mr. during the evening.2 mental status and safety in the home environment. to also meet with Mr. Allen’s sleeping pattern and finds out that he is not up at night except for an occasional trip to the bathroom. respect. Allen’s daughter. Simulation Scenario 2 occurs in the Allen’s home. Allen explains that her weight loss is related to the changes she has made in her diet and physical activity. her pastor) if not with her or the nurse. and Mrs. Mrs. Monologue (visiting nurse) the nurse realizes that Mrs. Monologue (visiting nurse) Mrs. Allen replies that she is always busy and barely has any more time to continue her involvement with her church activities. Allen replies: “I have a lot of things on my mind and in my heart”. At the next visit. Mrs. and her true presence when she is visiting this family but is hesitant to ask direct questions regarding Mrs. While Mrs. When asked about these changes. The nurse assesses Mr. Her daughter encourages her to share her worries with someone she trusts (i. Allen. the nurse meets with Mrs. The daughter is also concerned about her mother’s weight loss and decreased sleep. and she reports a decrease in sleep to about four hours per night. as it is. Allen and schedules her next visit in the evening. The nurse makes deliberate efforts to convey empathy. e. looks tired. Allen’s feelings. The nurse expresses her concern about the recent changes in Mrs. but does not elaborate. Allen is reluctant to share her feelings not only with her family members but also with a trusted religious figure (it turns out later that this is a . During this visit. she agrees that her stress level has recently increased. Allen’s appearance compared to a month prior: she is thinner. the nurse notices some changes in Mrs. with daughter present throughout the visit.

Allen comes to her appointment wearing a neat summer dress and a cotton hat. facing Mrs. She also denies any . Mrs. Allen to tell her briefly what brought her in. Allen. Allen and her daughter. diet and exercise. Sally invites her to sit down and asks her if she’d like a bottle of water. drinking alcohol or using illicit drugs. After some deliberation and encouraging from both visiting nurse and her daughter. Allen resides. while she is refusing medication. recently assigned to her church). a few weeks later.3 new. slightly leaning forward. She introduces herself and shakes Sally’s hand. The nurse carefully conveys her concerns to both Mrs. making eye contact. me not sleeping …I am taking care of my husband who has dementia and his nurse is also worried about my blood pressure creeping up. Sally Perry has worked as a Geriatric Mental Health NP in this community-based clinic for the past five years and is familiar with the neighborhood where Mrs. emphasizing that at this pace she may not be able to remain an effective caregiver for her husband.” Sally asks a few brief questions about her medical history. Mrs. At first. Allen has a significant family history of heart disease (both parents and siblings). Allen agrees to follow through with the referral. and the fact that Mrs. Allen’s blood pressure is steadily increasing (today’s value 146/82). as she grew up in the South. She invites Mrs. Allen denies any history of smoking. younger pastor. Based on this history. She suggests a referral for a consult with a Nurse Practitioner (NP) specializing in Geriatric Mental Health. persistent insomnia. Allen states: “My daughter is worried about my health. She finds out that Mrs. Mrs. The visiting nurse explained that this NP is familiar with issues related to dementia patients and their caregivers and that she is also prepared to treat medical conditions such as hypertension. Mrs. Allen declines and states that she is used to summer temperatures. Mrs. she has drastically reduced animal fat and salt intake and she is walking with a group of women from church 2-3 times per week at a local mall. Sally sits next to her desk. She is concerned about the weight loss. Simulation Scenario 3 occurs in the NP’s office. Mrs. her family heart disease history. Allen replied that there was nothing wrong with her mental health and dismissed the suggestion.

strong. Allen’s caregiving responsibilities for her husband. Sally also asks about Mrs. Monologue . Sally notices the dress fits slightly loosely on Mrs. Currently she is taking only calcium 1200 mg/day. 5mg/day for the next two weeks. Allen’s significant cardio-vascular family history and discusses a need to start antihypertensive medication. Referred by visiting nurse. how she feels about the situation. Sally concludes the visit praising Mrs. regular. with a knee pain level of 2/10. with follow-up for dose adjustment. Chief c/o: elevated BP. She prescribes Lisinopril po. Mrs. Currently taking no medication. She also emphasizes Mrs. but is unable to state exactly how much. She sets up her next clinic appointment in two weeks.4 chronic conditions (diabetes. but states she can’t complain because her children are consistent in their help. Allen becomes slightly guarded when asked about her own feelings. Allen’s body. Mrs. insomnia. She is 5’4” and weighs 135 pounds. She acknowledges recent weight loss. Mrs. lung. Allen describes a regular pattern of waking up around 2AM with inability to continue restful sleep afterwards.” In addition. She mentions support from her faith community and states her conviction that: “God will not give you more than you can bear. Her vital signs at the time of the visit are: BP 148/86 (sitting) and 146/82 (standing). kidney disease). She also orders lab work. caregiver to husband with Alzheimer’s. She had eight pregnancies that resulted in eight live births.PMHNP notes Presentation: 70 year old retired. . African American woman. HR 90. and about her sleeping pattern. Allen for her caregiving work and emphasizing a need to maintain her health. Allen agrees to take the prescription and is reassured by the fact that this is a generic medication that will not cost her “an arm and a leg”.

Insightful with appropriate judgment when presented with rationales for antihypertensive medication initiation. well groomed. but has a steady pattern of elevated BP in spite of dietary and physical activity recent changes.5 Family hx. overall congruent with mood. Blood glucose level –fasting (BGL). place. Smiling appropriately. F/u for med adjustment and further PMH diagnostic evaluation scheduled in two weeks. electrocardiogram (EKG) and urine analysis (UA). slightly constricted when asked how she “feels”. with good eye contact. Summary of findings: Client is in no apparent distress. denies ETOH. Further diagnostic studies: Full blood count (FBC). and person. oriented to time. Mood is stable and affect is appropriate. Treatment with Lisinopril po. Speech well modulated with slight Southern accent. Emphasizes gratitude when asked about her feelings. Lipid panel. Electrolytes. 5 mg/day initiated today. carefully choosing her words when answering questions. Liver and Thyroid functions . Sensorium and cognition appear intact. poised. illicit drugs use .. Cooperative throughout interview. with good short and long-memory recall. She is a caregiver to husband with Alzheimer’s and has support from co-resident adult daughter and her two sons. No other significant health hx. Renal. DSM IV assessment: Axis I: 311. Alert. Thought content includes religious/spiritual overtones in reaction to caregiving situation. minor depression . significant for cardio-vascular disease.0 r/o Depressive Disorder NOS. No evidence of delusions/hallucinations with coherent thought process. Mental status exam: Carefully dressed. somewhat guarded when discussing feelings. tobacco. Labs pending.

Recommendations: 1) Initiate antihypertensive medication with close monitoring for gradual dose adjustment 2) Psychosocial support: individual therapy (interpersonal approach). family meetings. her symptoms are related to her dementia caregiving situation and it is very likely they will exacerbate as her husband’s condition worsens. Her night sleep remains limited to 4-5 hours . Husband’s condition is deteriorating. referral to caregiver support group 3) Consider antidepressant medication if symptoms exacerbate Simulation Scenario 4 occurs in the PMHNP’s office two weeks later. low fat diet and regular physical exercise. client voices no suicidal/homicidal ideation. She reports maintaining her diet and the same level of physical activity. no more than slight impairment in social functioning with meaningful interpersonal relationships Prognosis: Hypertension: good with medication compliance and maintenance of low sodium. Mrs. she appears to have a strong support system at home and has strong spiritual/religious beliefs.6 Axis II: Deferred Axis III: Hypertension Axis IV: Spousal dementia caregiver for past five years. Allen’s prognosis depends on the support she receives in her role as dementia caregiver. Axis V: GAF=80: insomnia. Her BP today is 142/72 (sitting) and 140/70 (standing). Depression NOS: fair . Allen reports compliance with Lisinopril and denies any unusual signs and symptoms. Her appetite is unchanged and so is her weight. Mrs.

Allen: “Many years ago. Allen: “I worry about the future. just fresh out of school. but he repented and I found it in my heart to forgive him and now he needs us …he was never a lazy man.” Sally: “A heavy load to carry…all these thoughts…have you talked with someone in church. I know how much dementia can take away from a person. Allen dozes off in the afternoon. but she reports taking a nap at the same time Mr. that I won’t be keeping my promise…although there was a time when I kicked him out of the house when I found out he had someone on the side…” Sally: “Some time ago?” (nodding her head) Mrs.7 per night. Sally reviews Mrs. Allen: “Yes. he provided for us and now he can’t even take care of himself. what was it like talking to your old pastor?” . Allen’s lab results which are within normal limits. your pastor?” Mrs. I don’t know him well…I used to talk with the old pastor before he passed a year ago” Sally: “I am sorry to hear about his passing. The following dialogue ensues: Sally: “What thoughts come to mind in the middle of the night?” (leaning forward and following client’s gaze) Mrs.” Sally: “You worry that you may have to make a decision about placement soon?” Mrs. I’ve seen it first hand when I used to work in a nursing home. you must be missing him. we were in our 40’s. Allen: “He’s a youngster.

as she has no history of mental illness. and D do not apply to Mrs. . For example. Allen. “ The visit concluded with setting up a new appointment in another week. Criteria B. Allen: “I did feel relief. Allen in her caregiving role. Allen is grieving these losses. Allen meets only one item on criterion A for minor depressive disorder: insomnia nearly every day. I don’t know about later? I don’t like to stir things up from the past” Sally: “Thank you for sharing these deep thoughts and feelings you are having about Mr. he was an understanding man and he knew us from way back. dementia has taken a lot out of him as a person. Allen. Mrs. there is a tinge of guilt in her story about kicking him out of the house for his indiscretions. it really helps me see what your needs are as a caregiver. Allen: “Right now. C. he knew our difficulties…I can’t believe I’m telling you all this stuff” Sally: “Do you feel some relief when talking to me?” (smiling) Mrs.8 Mrs. Some fatigue may be due in part to lack of restful sleep at night and to demanding hands-on care provided for her husband. Monologue (PMHNP) Differential diagnosis: Depression NOS/minor depressive disorder Mrs. In addition. for further monitoring of medication and planning further support of Mrs. father and grandfather. Although he is physically alive. I do. her weight loss may be due to her dieting. Allen’s brief statements about her husband indicate her longing for who he used to be. Mrs. most items under criterion A do not apply to her or are debatable. her weight did not change in the two week interval since first appointment. husband.

195. (2007).1000121 Sanders. M. Ott. S. S. Kelber.. Death Studies . 3.. Research in Gerontological Nursing . H.H.. (2003)... Ott. Spousal Bereavement in Older Adults: Common. H. 47. Aslan M. C. Blaylock. Allen suffers from chronic grieving related to years of providing care for a spouse with dementia. Kelber. Lueger.. R. 8999. & Prigerson.9 Although there are no available DSM IV-TR criteria. Sander. Created: 2011 . The impact of complicated grief on mental and physical health at various points in the bereavement process. (2010). Prigerson HG. The Gerontologist . Readings: Ott. 31.. Jacobs SC. PLoS Med 6(8): e1000121. S.H. Parkes CM. doi:10. 27. (2009) Prolonged Grief Disorder: Psychometric Validation of Criteria Proposed for DSMVand ICD-11.pmed. Ott. family and group counseling. 495-523.H. Recommendations for treatment include f/u for antihypertensive medication adjustment and grief-focused supportive individual. S. Resilient and Chronic Grief with Defining Characteristics . Easing the way for spouse caregivers of individuals with dementia: A pilot feasibility study of a grief intervention.. 798-809. S. 332-341.1371/journal. & Kelber. Kelber. Horowitz MJ. S. et al.. Grief and personal growth experiences of spouses and adult child caregivers of person's with Alzheimer's disease. C. C. (2008). The Experience of high levels of grief in caregivers of persons with Alzheimer's disease. C. it is safe to say that Mrs. Death Studies.H. Journal of Mental and Nervous Diseases . C. (2007). Ott. 249-272.