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Title: Clinical Case Discussion – Evaluating Eleanor’s Cognitive and Behavioral Changes
Introduction:
In this case, we are presented with Eleanor, a 77-year-old white female residing in a skilled nursing facility. Eleanor’s daughter has recently requested an evaluation of her mother’s worsening Alzheimer’s symptoms. Eleanor was admitted to the facility six months ago due to moderately severe cognitive and physical decline, along with her inability to manage herself at home. Her daughter, a single mother of four teenagers, faced challenges in providing the necessary care for Eleanor after a kitchen fire incident. Eleanor’s cognitive decline started in her late fifties and worsened significantly following her husband’s death five years ago.
Clinical Summary:
Eleanor’s recent behavior in the skilled nursing facility is causing concern. She has become restless, frequently wandering the halls and attempting to open fire doors when confused about her surroundings. Moreover, she exhibits combative behavior, including verbal aggression and physical aggression towards the nursing staff. Her primary care physician authorized the use of restraints after Eleanor wandered out of the facility and was found trying to take a dog from a woman, all while expressing paranoia about people stealing her clothing in the nursing home.
List of Patient’s Problems and Prioritization:
1. Cognitive Decline: Eleanor’s worsening cognitive decline is the primary issue, impacting her daily functioning and safety.
2. Behavioral Disturbance: Her combative and restless behavior poses risks to both herself and the nursing staff.
3. Paranoid Delusions: Eleanor’s belief that people are stealing her clothing is indicative of paranoid delusions.
Diagnosis:
Eleanor’s primary diagnosis should be Alzheimer’s Disease. The rationale for this diagnosis is based on her age, cognitive decline, and memory impairment, which are characteristic features of Alzheimer’s disease. Her family history of cognitive decline and the progressive nature of her symptoms align with this diagnosis.
Differential Diagnosis:
Differential diagnoses should include other dementias such as Vascular Dementia and Dementia with Lewy Bodies, which can present with overlapping symptoms. Additionally, a delirium assessment is warranted due to her acute behavioral changes. Depressive disorders may also contribute to her cognitive and behavioral symptoms.
Tests and Screening Tools:
1. Mini-Mental State Examination (MMSE) to assess cognitive impairment.
2. Brain imaging (MRI or CT scan) to identify structural brain abnormalities.
3. Delirium screening tools to rule out acute cognitive changes.
4. Evaluation for depression, including the Geriatric Depression Scale (GDS).
Treatment Plan:
1. Psychopharmacology: Consider cholinesterase inhibitors (e.g., Donepezil) to slow cognitive decline associated with Alzheimer’s.
2. Diagnostic Tests: Brain imaging to confirm structural abnormalities.
3. Referrals: Consultation with a geriatric psychiatrist for medication management.
4. Psychotherapy: Cognitive-behavioral therapy for managing behavioral symptoms.
5. Psychoeducation: Provide education and support to Eleanor’s daughter and family members on managing Alzheimer’s disease.
Standard Guidelines:
The assessment and treatment should adhere to guidelines from organizations like the Alzheimer’s Association and the American Psychiatric Association. These guidelines emphasize the importance of accurate diagnosis, patient and caregiver support, and evidence-based interventions for Alzheimer’s Disease.
In conclusion, Eleanor’s case presents a complex situation that warrants a thorough evaluation, considering the potential diagnosis of Alzheimer’s Disease and differential diagnoses. A multidisciplinary approach, in alignment with standard guidelines, is crucial to assess and treat her cognitive and behavioral changes effectively.
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