Is Mrs. Washington’s condition serious enough to put her at risk for self-harm?

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

Mrs. Washington sometimes wanders at night and could become injured by a fall. Being outside at night could make her vulnerable to victimization, expose her to adverse weather conditions, or she could get lost. Mr. Washington reports that his mother left lit cigarettes around the house and started several small fires. Her risk of self-harm is reduced when she has a caregiver with her, but her son had reached the age where he could not function adequately in that role.