Case Study 141 Dementia

1. What are some cognitive changes seen in a number of

elderly patients?

Cognitive changes are normally seen in elderly patients. Some changes

include cognitive abilities, vocabulary, conceptual reasoning, memory,
slower problem solving, diminished spatial orientation and processing
speed.

2. You know that physiologic age-related changes can

influence cognitive functioning. Name and discuss one.

Physiological age-related changes that can influence cognitive

functioning, an example would be reduced visual acuteness and
accommodation can result in diminished capability to process visual
cues. Flattening and yellowing of cornea can lead to difficulty
distinguishing colors. Moreover, lesser functional cochlear cells can
lead to diminished ability to process a person’s auditory input.

3. For each behavior listed, specify whether it is associated

with delirium (DL) or dementia (DM).

a. Gradual and insidious onset DM

b. Hallucinations or delusions DL
c. A sudden, acute onset of symptoms DL
d. Progressive functional impairment DM
e. Inability to perform activities of daily living (ADLs). DL
f. Incoherent interactions with others DL
g. Possible wandering behavior DM
h. Behavioral disorders that often worsen at night DL

4. Based on the information provided by the daughter, do you

think K.B. is showing signs of delirium of dementia? Explain.

Based on the information provided by the daughter, we can conclude

that K.B is showing signs of dementia. His wandering behavior at the
streets, the functional impairment with the way he cannot pour his own
coffee, and his slow and insidious onset.
5. You know that there are several types of dementia that
result in cognitive changes. List two of these types of
dementia.

Lewy Body Dementia - is a disease associated with abnormal deposits

of a protein called alpha-synuclein in the brain. These deposits, called
Lewy bodies, affect chemicals in the brain whose changes, in turn, can
lead to problems with thinking, movement, behavior, and mood.

Alzheimer’s Dementia - a type of dementia that causes problems with

memory, thinking and behavior.

6. How can the level or degree of the dementia impairment be

determined?

The progressive nature of symptoms are described in stages 1-7:

Stage 1: No impairment - no symptoms of impairment, mental function

is normal
Stage 2: Very mild cognitive decline - forgetting everyday phrases,
forgetting location of important objects
Stage 3: Mild cognitive decline - impaired work performance, memory
loss, verbal repetition, poor organization and concentration, difficulty
driving
Stage 4: Moderate cognitive decline - social withdrawal, moodiness,
non responsive, trouble with routine tasks, denial
Stage 5: Moderate severe cognitive decline - confusion, memory loss of
personal details and current events, reduced mental acuity
Stage 6: Severe cognitive decline - middle dementia or moderately
severe Alzheimer’s disease
Stage 7: Very severe cognitive decline - Alzheimer’s disease or late
stage dementia

7. A number of diagnostic tests have been ordered for K.B.

From the tests listed, which would be used to diagnose
dementia?

Mental status examinations

Toxicology screen
Mini-mental state examination
Electrocardiogram
Complete metabolic panel
Compete blood count with differential
Thyroid function test
Serum b12 level
Bleeding test
HIV virus screening
Liver function test
Magnetic resonance imaging

8. What neuroanatomic changes present in individuals with

Alzheimer’s Dementia?

Neuroanatomic changes that are present in individuals with

Alzheimer’s Dementia is that the convoluted atrophy of the brain which
means that there is a complicated loss of brain cells or a loss in the
number of connections between brain cells, another neuroanatomic
change is that microscopic plaques and tangles, chiefly in the cortex
and hippocampus areas of the brain. he presence of plaques around a
neuron causes them to die, possibly by triggering an immune response
in the immediate area. Tangles form inside of neurons and interfere
with the cellular machinery used to create and recycle proteins, which
ultimately kills the cell.

9. List at least three interventions you would plan for K.B.

Interventions that I would plan for K.B:

1. Teach his daughter to provide a safe environment at home for K.B.,

and include activities that would permit K.B to do things by himself
unassisted but be sure to follow safety precautions.
2. Do not change K.B’s daily activities, his everyday routine should still
be followed.
3. Give physical exercise programs
4. Do not allow him to go out alone if he is prone to disorientation
5. Conduct risk assessment for falls

K.B. is discharged and sees his primary care physician 2

days later. K.B. receives a prescription for donepezil
(Aricept) 5 mg PO per night. As you review the
prescription with K.B’s daughter, she tells you that she is
“excited” because she did not know there were
medications that could cure Alzheimer’s Disease.

10. How do you respond?

I would be up front with K.B’s daughter and tell her that Alzheimer’s
Disease is not curable. The medications are only there to possibly
alleviate the symptoms and properly manage the effects, but it cannot
cure the disease completely. Also, donepezil is for the early stage
management of the disease, it changes overtime; the dosage. So I
would tell her not to get too excited about it because it is to manage
symptoms of that particular stage only.

Two weeks later, K.B.’s daughter calls the physician’s

office and states, “I realize that the Aricept will not cure
my dad. But there has been no improvement at all. Are we
wasting our money?”

11. What is the best answer for her?

It has only been two weeks since K.B. is taking the medication. This
medication might take 4 to 6 weeks for a visible effect to be noted. For
now, she needs to be patient aand administer the medication to K.B.
more time to have an effect.

12. K.B.’s daughter mentions that she has found him out in the
front yard and once in the neighbor’s yard. What are some
interventions that you can suggest to promote safety for K.B.?

> Consider installing a device that would alarm and provide warning if
K.B opens up the door
> Inform neighbors and local law enforcement about K.B’s wandering
tendencies
> Place locks on doors that are difficult to open
> Obtain CCTV where K.B’s daughter can monitor the whereabouts of
K.B even when inside the house