Instructor’s Overview: George Palo —

Adjustment Disorder with Depressed

Mood
Scenario Overview
Patient: George Palo

Diagnosis: Adjustment disorder with depressed mood

Brief Summary:

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George Palo is a 90-year-old male who was diagnosed 6 months ago with minor neurocognitive disorder,

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Alzheimer’s type, which is currently being treated with galantamine. After George’s wife of 65 years,

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Anna, died 3 years ago, George moved into a small one-bedroom apartment in an independent-living
retirement community. He has mild hypertension, and a nurse employed by the retirement community

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visits weekly to take his blood pressure. He takes atenolol daily, which keeps his blood pressure under
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control.

Until 2 months ago, George was doing well, keeping very active by walking every day with his 13-year-old
golden retriever, Max, and occasionally going hunting. Then Max died, and George has since declined.
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His confusion is increasing, he forgets to pay bills, and he has lost weight. His daughter, Maggie, is
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concerned about this decline and has asked the community health nurse to make a visit. The simulation
starts with the students coming to see George in his home, with both George and Maggie being present.

During the simulation, the students will be expected to use appropriate tools to assess for depression
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and reassess cognition. The students will also be expected to consider suicide risk and—although
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George’s answer will leave no doubt that he is not currently suicidal—to suggest the option of removing
the gun from the house. Furthermore, the students should provide emotional support to George for his
losses and discuss adjustments in his activities that can help to maintain his optimal level of function and
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independence.
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Learning Objectives
General:
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□ Identify the psychopathology of mental health disorders

□ Assess contributory factors affecting care, including but not limited to psychosocial, cultural,
spiritual, environmental, and socioeconomic factors
□ Establish a therapeutic milieu that engages psychiatric patients and their families

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 vSim for Nursing | Mental Health
George Palo

□ Identify the indications, therapeutic effects, side effects, and teaching implications of drugs used
to treat the symptoms of mental health disorders
□ Provide a safe environment for both patients and staff
□ Recognize communication patterns and use therapeutic communication techniques that
illustrate caring for the patient’s overall well-being
□ Apply the nursing process to prioritize the plan of care
□ Communicate appropriately with the therapeutic team in a timely, organized, collaborative, and
patient-specific manner

Scenario-Specific:
□ Perform a focused physical assessment to assess vegetative symptoms and weight loss
□ Reassess cognition with the Mini-Cog assessment tool
□ Evaluate depression with the Geriatric Depression Scale tool
□ Differentiate between neurocognitive decline and depression

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□ Interpret findings from assessments and recommend a plan of care

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□ Use therapeutic communication techniques to respond to a patient with neurocognitive decline

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and depression

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Patient Case Introduction to Students
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Location: Apartment in a retirement community (independent living)
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Time: 14:00
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Report given by one of the nurses employed at the retirement community to the community health
nurse who is making the visit:
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Situation: George Palo is a 90-year-old male who has been living independently in one of our apartments
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since shortly after the death of his wife of 65 years, Anna, 3 years ago. George was diagnosed with minor
neurocognitive decline, Alzheimer’s type, 6 months ago and prescribed galantamine. He also has mild
hypertension and is being medicated for that, as well. George was managing well until 2 months ago,
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when Max, his 13-year-old golden retriever, died. Maggie, his daughter, recently contacted us and asked
for a visit because she is concerned that George seems to have become more forgetful and weaker, and
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she thinks his clothes look bigger, so he may have lost weight recently.

Background: One of the nurses from your agency made a visit to George 7 months ago at the request of
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his daughter, who was concerned at that time about his memory. Your agency nurse did a physical and
cognitive assessment using the Confusion Assessment Method (CAM) and Mini-Cog tools. The CAM was
negative for delirium, but some impairment in executive functioning was evident. You can review the
result of the Mini-Cog tool in the chart. Your nurse suggested some memory aids and resources to help
him maintain independence and recommended that he see his physician, who later diagnosed him with

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 vSim for Nursing | Mental Health
George Palo

Alzheimer’s disease and prescribed galantamine. Since then he has been managing very well with his
new medication—that is, until Max died.

Assessment: George’s blood pressure has been well controlled these past few months. We have been
visiting him on a weekly basis to check it. Previously, we frequently saw him out walking with Max—daily
or sometimes even more often. He worked as a volunteer at the Humane Society. But since Max died, we
rarely see him, and when we do, he looks sad and disheveled.

Recommendation: I administered the Geriatric Depression Scale yesterday when I visited George to take
his blood pressure. The result is in the health record for your review. In addition, I recommend that you
do a focused physical assessment to address his daughter’s concerns about his physical condition. Please
also reassess his cognition with the Mini-Cog tool and compare with the previous result. Maggie will be
there during your visit. Communicate your findings to me or one of the other retirement community
resource nurses and to his physician if you think he needs to be seen again before his next scheduled
visit.

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Patient Details

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Patient Data: Male, African-American, 90 years old. Weight: 85 kg; Height: 180 cm

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Date of Birth: 4/1/XX
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Allergies: Penicillin

Past Medical History:

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□ Minor neurocognitive disorder, Alzheimer’s type, diagnosed 6 months ago and treated with
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galantamine
□ Mild hypertension, treated with atenolol
□ Also taking daily aspirin and multivitamin
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□ Otherwise healthy and very active until recently

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Provider’s Orders
□ Not available
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Overview of Proposed Correct Treatment

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□ Perform a scene safety check

□ Wash hands
□ Identify the patient
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□ Get consent from the patient for letting his daughter be a part of the interview
□ Support the patient in the loss of his wife and dog
□ Obtain vital signs, including lung sounds, and perform a skin assessment
□ Assess pain
□ Assess weight, appetite, sleep, and energy
□ Perform a safety check of the patient’s belongings and remove potentially dangerous items

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 vSim for Nursing | Mental Health
George Palo

□ Perform a Mini-Cog assessment

□ Provide patient education about the difference between grief and depression
□ Provide patient education about coping
□ Provide patient education about getting active
□ Refer the patient to a physician
□ Call the community nurse and report findings
□ Use therapeutic communication throughout the case

Case Considerations
It is important to differentiate between depression and neurocognitive disorder. Sometimes the
symptoms of depression can mirror symptoms of neurocognitive disorder. Depression may also
exacerbate some of the behavioral and cognitive symptoms that accompany neurocognitive disorder,
resulting in some instances in increased aggression, confusion, problems with sleeping and nutrition, or
forgetfulness. Changes in speech, inability to reason, or lack of spatial perception would be unusual

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features of depression but could be impairments seen with neurocognitive disorder. With cases of severe
depression, lack of reasoning and memory may mirror that of neurocognitive disorder; however, with

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appropriate treatment for depression, this feature often reverses, whereas it does not with
neurocognitive disorder.

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The relationship between grief and depression is complex, yet the two can be differentiated. Responding
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to loss of any kind can precipitate feelings of sadness, changes in sleeping and eating patterns, etc. These
are not unusual symptoms and generally resolve. Grief symptoms that persist longer than a few months
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have likely triggered the onset of a depressive episode. Patients should then have a more extensive
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evaluation, as treatment for depression and grief can significantly improve outcomes.
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Note that changes in physical appearance will require the completion of a physical assessment in
addition to assessing mental and cognitive health. The physical assessment will inform how severe the
mental and cognitive health deficits are.
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