Could Mrs. Washington’s symptoms be related to medical causes or to her use of any substances?

Question

DSM Diagnosis
294.10 Major Neurocognitive disorder due to Alzheimer’s disease, with behavioral disturbance, severe
310.0 Alzheimer’s disease
Hypertension, lumbago, urinary retention, constipation

Rationale
The client’s NCD began approximately one year ago with a gradual decline in her cognitive functioning. The cognitive deficits consist of the following: memory impairment, impaired ability to carry out motor activities (getting in and out of bath) including fine motor activities (knitting); and disturbance in executive functioning as evidenced by disorganization and problems with sequencing. A medical factor does not seem to be a contributing influence for the dementia, although urinary retention may often lead to a urinary tract infection, which can cause delirium if left untreated over time. Mrs. Washington has become increasingly confused and exhibits aggression due to confusion, especially in the evening hours.

Additional Information Required
As discussed, Alzheimer’s disease needs to be diagnosed by a physician and medical examinations and tests are used to rule out other conditions that may account for Mrs. Washington’s symptoms.

Treatment
Mr. Washington was at the point where he was no longer able to cope with the demanding care of a person who suffers from dementia. The social work intern discussed options other than long-term care, such as behavioral strategies to control some of her symptoms mood and respite care. Mr. Washington was emphatic, however, that he was no longer able to attend to her care in his home.
While his mother was in the hospital, the social work intern helped Mr. Washington find several facilities that would accommodate his mother for rehabilitation and later long term care. Long-term care also required an application for Medicaid, even though Medicare and a commercial insurance company covered Mrs. Washington. This was a challenge for Mr. Washington who never had to deal with the paperwork; his brother, who had recently moved out of state, assumed these tasks previously. Mr. Washington chose several facilities that would be able to accommodate his mother; he visited them and gave the social work intern a preference list. The social work intern performed the initial referrals.
Physical and occupational therapy is another important aspect of the care with people who suffer from Alzheimer’s disease. Physical and sensory stimulation activities are empirically validated as effective with those clients (Bharani & Snowden, 2005). Mrs. Washington started those therapies while in the hospital and they will continue after her discharge.
Another aspect of the treatment plan for Mrs. Washington is medication. Mr. Washington reported that his mother takes medication for the symptoms of the dementia. She will be evaluated as a candidate for one of the cholinesterase inhibitors, which have been shown to slow the progression of Alzheimer’s disease in some cases (Olsen, Poulsen, & Lublin, 2005). She may also be prescribed a low dose of an antipsychotic medication if her agitation continues to be an issue in her care and behavior. Because all of these drugs are associated with adverse effects in older adults, the client’s tolerance of them will be carefully monitored

Critical Perspective
Alzheimer’s disease is a serious, highly debilitating condition that is best treated when diagnosed early. Still, the absence of tests to positively determine the disorder makes the diagnosis difficult. In Mrs. Washington’s case it is possible that her symptoms may be due to some other organic cause that cannot be determined. For that reason it is important for assessment to be an ongoing process, by the medical and social services team, to insure that the client is being treated for the correct disorder. Because AD is a “rule in” diagnosis, there is always the possibility that it is an incorrect diagnosis, especially in the early stages.

Answer 1

Some forms of NCD are caused by medical conditions, and some of those are reversible. Mrs. Washington (who is 89 years old) has been diagnosed with lumbago and urinary retention, neither of which is associated with dementia. Mrs. Washington had a series of tests last year so it is assumed that medical conditions, including circulatory problems, were ruled out as causes of her NCD. Therefore, she does not suffer from the problems that are known to be associated with vascular dementia.
Regarding her health history, Mrs. Washington’s son reported that she followed a high-fat diet for most of her life and ate many fried foods. She is a long-term smoker, which is a risk factor for both dementia in general, and in the Alzheimer’s type specifically, so there may be some connection with her history of being a cigarette smoker. She also used to drink two bottles of beer every night with dinner until about two months ago when Mr. Washington started to give his mother non-alcoholic beer. Thus it seems that she experienced several risk mechanisms for NCD, but that her disorder is not the result of current circulatory problems that are known to be associated with, for example, vascular dementia.