Are there any recent stressors that may account for the client’s symptoms presentation?

Question

DSM Diagnosis
294.11 (F02.81) Major Neurocognitive Disorder due to Alzheimer’s disease, With Behavioral Disturbance, Severe
290.42 Major Vascular Neurocognitive Disorder, With Behavioral Disturbance, Severe
310.1 Personality Change Due to Alzheimer’s Disease
331.00 Alzheimer’s disease
250.00 Diabetes mellitus, type II/non-insulin-dependent
436.00 Stroke (earlier this year)
401.90 Hypertension (six years ago)
714.00 Arthritis, rheumatoid
Atrial Fibrillation (six years ago)

Rationale
Mr. Grahm was diagnosed with Major Neurocognitive Disorder due to Alzheimer’s Type, with the following criteria:
Criterion A: The development of multiple cognitive deficits
? (1). Memory impairment: Mr. Grahm does not remember family and friends. He forgets recent events and card games and he repeats himself many times in the same conversation.
? (2) Cognitive disturbances (one symptom required):
? Mr. Grahm is unable to plan and organize sequenced behavior, such as making toast or managing his checkbook. Further, he cannot follow two-step instructions. These represent disturbances in executive functioning.
Criterion B: Evidence of impairment in occupational functioning (Mr. Grahm had to stop his volunteer work) and social functioning (Mr. Grahm is suspicious of and in conflict with family members because of his memory impairment and delusions).
Criterion C: Starting 10 years ago Mr. Grahm’s family noticed a gradual decline in his cognitive functioning, which has progressed since then.
Criterion D: His medical history does not indicate any conditions of the nervous system, nor does it indicate any systemic conditions known to cause dementia. Mr. Grahm denies any history of substance abuse.
Criterion E: Mr. Grahm’s symptoms are persistent and not due to a period of delirium.
Criterion F: Mr. Grahm does not show signs of depression or schizophrenia.
With Behavioral Disturbance: Mr. Grahm wanders in the evening around the house. He is irritable and blaming of his caregivers.
With Late Onset: Mr. Grahm’s symptoms started after he was age 65.
Mr. Grahm was also diagnosed with Major Vascular Neurocognitive Disorder with the following criteria:
Criterion A, B, and D are similar for the above justification for Dementia of the Alzheimer’s Type.
Criterion C: Six years ago Mr. Grahm was hospitalized for minor strokes.
With Delusions: Mr. Grahm thinks that family members and strangers are stealing from him.
Finally, Mr. Grahm received a diagnosis of Personality Change Due to Alzheimer’s Disease.
Criterion A: Several years after the onset of Alzheimer, for the first time in his life, Mr. Grahm became suspicious of the family and strangers stealing from him. He began checking the doors repeatedly and hid his personal items.
Criterion B: Mr. Grahm’s team of doctors determined that his paranoia was due to Alzheimer’s disease.
Criterion C: Mr. Grahm has no other known disorder that might account for his personality changes
Criterion D: The disturbance does not occur exclusively during the course of a delirium. Criterion E: Social impairment is evident in that Mr. Grahm’s anxiety and paranoia affect the relationship with his primary caregivers.
Mr. Grahm has serious symptoms of dementia including hallucinations, which keep him up for hours each night. He has risk of self-harm; his wandering behaviors could lead to serious physical injury (for example, if he falls down the stairs), and he has impaired memory and judgment about his activities of daily living. Further, Mr. Grahm’s symptoms ostracize others because he is often accusatory and agitated due to delusions.

Additional information needed:
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 Mr. Grahm’s symptoms.

Risk and Resilience Assessment

Onset of Alzheimer ’s disease and Vascular Dementia

Treatment
The medical team has been prescribing Mr. Grahm Neurotin, Ativan, and Zyprexa to stabilize his mood and control hallucinations, Depakote to decrease his tremors, Vasotec for his blood pressure, and Folic Acid and Razadyne for his dementia. The drugs are intended to relieve Mr. Grahm’s distress and slow the course of the dementia. Older adults tend to be sensitive to the adverse effects of medications, especially the antipsychotic and cholinesterase inhibitors (Bharani & Snowden, 2005), so the social worker should carefully monitor the client’s tolerance of these substances over time.
The treatment team has suggested that the family consider in-home care or hospice care for Mr. Grahm since they cannot control predict or control his behavior and feel that he is unsafe in the home. The agency’s psychosocial goals for the client include:
? To develop and follow a restroom schedule
? To develop a consistent daily routine
? To increase his level of physical functioning
? To reduce feelings of anxiety
? For the family to become more knowledgeable of community services available
? To stabilize blood sugar through diet
? To stabilize his sleeping pattern
? To maintain his support systems
These goals require coordination between Mr. Grahm, the medical professionals, the social worker, and Mr. Grahm’s family. An in-home care professional can help the family develop and follow a routine of consistent care for Mr. Grahm so that he is not left alone so often. Further, the in-home-care professional can ensure that Mr. Grahm uses the restroom. The in-home-care professional can also work with Mr. Grahm to move around during the day, thus helping him to sleep better at night and increase his physical functioning. Senior activities or scheduled activities with the family could help with this goal as well. Such activities have been shown helpful in slowing the progression of AD and enhancing the client’s quality of life (Olsen, Poulsen, & Lublin, 2005). Having a consistent routine with the same people and the medications will help Mr. Grahm maintain his current level of cognitive functioning. Connecting Mr. Grahm with a Senior group for Alzheimer that reminisces may help maintain cognitive functioning as well as help him develop more supports.

Critical Perspective
The DSM-IV-TR does not have a single code for someone suffering from more than one type of dementia. Although both diagnoses in this case suggest similar medical interventions, coding is needed to properly communicate the disease the client is experiencing. In the DSM-IV-TR, there is a coding option for Vascular Dementia with Delusions, but there is no option to code delusions as the prominent feature in Dementia of the Alzheimer’s type. This is curious because the research on both Vascular Dementia and Dementia of the Alzheimer’s type report that delusions can be a symptom of both. Along the same lines, with Dementia of the Alzheimer’s type, the practitioner is required to code the behavioral disturbance. However, there is no coding requirement for behavioral disturbance in Vascular Dementia. Consistency between the coding of these disorders would be important for insure diagnostic validity.

Answer 1

Mr. Grahm’s loss of physical mobility and cognitive clarity clearly present him with serious stressors. He has lost certain “freedoms” that he will never regain. These losses may be the source of some of his increasing frustration and agitation, but they do not account for his primary symptoms of memory impairment.