PATHOPHYSI NR 507 Week 7: Behavioral, Neurologic, and Digestive Disorders - Discussion Part Two

Lorna Durfee 6/13/2016 2:50:10 PM Discussion Part Two Your patient is a 77-year-old woman who has been more socially withdrawn lately and told her daughter she had not been feeling well. Her daughter has noticed a stepwise decline. While shopping for groceries with her daughter, she became separated from daughter in the aisles. She became confused and angry when store employees and others tried to assist her. Her current medications are Hydrochlorothiazide, Lisinopril, and Atorvastatin. • What is your differential diagnosis based on the information you now have? • What other questions would you like to ask her now? (Questions can be asked of patient first, and then of reliable historian separately.) • How would you treat this patient and discuss why you give each medication or therapy you give. Doctor Brown: This patient appears to be exhibiting signs of loss of memory and having difficulty finding her way. She also demonstrates some agitation. From her symptoms and signs, she is exhibiting forgetfulness along with confusion and irritability; this could be the start of Alzheimer’s or dementia. When evaluating this patient consideration of current medications are vital. There can be drug interactions and toxic effects of certain medications. This patient may be exhibiting signs of toxic drug reaction. As we age, our body does not filter out medications as easily as when we were at a younger age. There could be a side effect or interaction occurring with her medications. As for her medications, The American Geriatrics Society, and Beers Criteria recommends that in patients over 65 years of age to use caution when prescribing diuretics. There is a risk of the syndrome of inappropriate antidiuresis, or hyponatremia when using Hydrochlorothiazide (Dynamed, 2016). This patient could be exhibiting the beginning of potassium depletion or hyponatremia. There is no indication of what her fluid consumption has been or what her electrolyte levels are. There can be adverse effects with an excessive reduction in blood pressure such as with orthostatic hypotension with the use of Hydrochlorothiazide. Confusion can be a symptom of adverse effects from the drug (Dynamed, 2016). Lisinopril – This is an ACE inhibitor and antihypertensive medication. This medication, when used in the geriatric population, needs to be used with caution. Another thing to consider, when using this medication, is decreased hepatic, renal and cardiac function. This medication can also cause hypotension (Dynamed, 2016). Atorvastatin - An HMG-CoA Reductase Inhibitor. This medication can be a factor for myopathy in the geriatric population. Before the use of this medication the adverse effects, drug interactions, and patient preferences should be reviewed. It is also an antilipemic agent. As a side effect from this medication, the patient may also be experiencing hyperglycemia effects. The side effect of cognitive impairment is rarely reported with use of this medication. Because there is a component of cognitive impairment in this patient, the National Lipid Association (NLA) statin safety assessment task force recommends evaluating this patient for a statin. They also recommend evaluation for non-statin causes, such as other medications, systemic or neuropsychiatric causes (Dynamed, 2016). What other questions would you like to ask her now? (Questions can be asked of patient first, and then of reliable historian separately.) When asking this patient questions we could begin by asking her if she is feeling confused and overwhelmed. We could use a very calm demeanor. We would ask about her eating, sleeping, bowel movements, and do a system review. If she cannot answer those questions, the caregiver who accompanies her can help with this. We would also need to do a physical exam. Then we would need to do a mini-mental exam. We could use the Folstein mini-mental questionnaire. We could ask her if she knows where she is. We could also ask if she knows the date, the time, the President, and her name. We could have her spell a “WORLD” backward. We must assess her mental status and review her medications. The family members that accompany this visit could fill us in on details of what they have observed and give a detailed history. We could run some further blood tests to determine if there is any metabolic condition underlying this change. What is your differential diagnosis based on the information you now have? I think that this patient shows signs of mild cognitive impairment and possible onset of dementia. The Alzheimer’s Association explains that dementia is not a specific disease but an overall term that outlines a range of symptoms that appear with a decline in memory or thinking. Dementia limits the person’s ability to perform activities of daily living. Alzheimer’s accounts for 60 to 80 percent of the cases of dementia, however, vascular dementia is the second most common type worse (Alzheimer's Association, 2016). There are other conditions such as thyroid or vitamin deficiencies that can cause problems. The Alzheimer’s Association lists some of the conditions under what is considered dementia. If patients have dementia at least two core mental functions must be impaired. The core mental functions are; memory, communication, and language, ability to focus and pay attention, reasoning and judgment and visual perception. There can be problems with short-term memory, paying bills, preparing meals and traveling into unknown and recognized areas. Dementias are progressive, and the symptoms can start slowly and then get worse (Alzheimer's Association, 2016). There are other problems that cause memory issues, such as; depression, medication side effects, excessive use of alcohol, thyroid and vitamin deficiencies (Alzheimer's Association, 2016). Mild cognitive impairment is a symptom first seen in the progression of Alzheimer’s Disease. There is mild memory loss for recent and new information in early stage Alzheimer’s Disease. In other words, there is short-term memory loss, difficulty with planning and disorientation to location. There is also possible depression and mild anxiety. There is also mild instrumental activities of daily living (McCance, Huether, & Brashers, 2014, p. 550). How would you treat this patient and discuss why you give each medication or therapy you give? Establishing the cause for this dementing process may be very complicated. However, patients should be evaluated with laboratory and neuropsychologic testing and brain imaging. The use of neuroleptic medications could be considered. If there is depression the use of antidepressants can be appropriate (McCance, Huether, & Brashers, 2014, p. 546). Moyer ( 2014) and The United States Preventative Task Force state that older aged people are a known risk factor for cognitive impairment. There are other risk factors such as diabetes, tobacco use, hypercholesterolemia, and hypertension. A history of head trauma, depression, and physi