How to write a nursing essay on Aggressive Behaviors in Patients with Dementia Case (Solved)

How to write a nursing essay on Aggressive Behaviors in Patients with Dementia Case (Solved)

Eva Harold Case

You are rounding on the inpatient geriatric unit. Your first patient is Eva Harold, who was admitted late yesterday after being discharged from her nursing home because of assaultive behavior.

Intake Note

Eva Harold, a 78-year-old woman, has been a resident of Carrot Patch Assisted Living for about two years. Her husband initially admitted her because of Alzheimer’s disease, associated memory decline, and progressive need for assistance with activities of daily living (ADLs) that could not be met by her family or community-based programs. She had a history of osteoarthritis but was otherwise healthy.
She had a Mini Mental State Exam (MMSE) = 18 (moderate cognitive impairment) on admission last night. Meds on admission were galantamine 24 mg daily and celecoxib 200 mg daily. Nursing staff describe Eva as a sweet lady. However, recently she began having confrontations with staff and has become increasingly restless and agitated. She even started hitting staff. These behaviors are especially prominent during the evenings.

She also seems sad and has been expressing helplessness and hopelessness in comments to staff. She recently shouted for an aide to leave her room—for unclear reasons—while the two of them were looking at pictures in one of her photo albums. She was restless and tense that day and, as the sun began to set, another resident approached her in her room, voices were raised, and Eva struck the other resident. Eva is now being assessed for her new onset of behaviors.

Physical examination, blood work, and medication review are negative. The short form GDS = 8 (above 5, positive screen for depression). She also appears sad and expresses helplessness and hopelessness. Her pain scale score is 0 out of 5 (zero being no pain).

Questions

From your perspective as Eva’s psychiatric nurse practitioner, answer the following questions in a three-or four page double-spaced paper (not including the reference page) in APA format. Include at least three peer-reviewed, evidence-based references.

1. What assessment and screening tools would you use with Eva?

2. What medications would you start? Please include the rationale for each medication you chose and starting dose, medication education, side effects, and any special considerations.

3. What are the steps to get her placed into a different nursing home? Please remember that she has a history of aggressive behavior and note that she has Medicare.

4. What resources and education would you give her family?

SOLUTION TO Eva Harold’s case

  1. What assessment and screening tools would you use with Eva?

Eva is a patient recently discharged from a nursing home care due to assaultive behavior. According to Eva’s symptoms, she is suffering from sundown syndrome that is commonly observed in patients with Alzheimer’s disease and dementia (Canevelli et al., 2016). This condition involves worsening neuropsychiatric symptoms in the late afternoon or early in the morning. Therefore before proceeding with further assessment, I will take a comprehensive history to determine the presence of any other symptoms. Sundowning presents with an array of symptoms including restlessness, irritation, disorientation, agitation, and anger (Canevelli et al., 2016). The following tools can further assist in screening for dementia and other psychiatric illnesses in the patient.

Saint Louis University mental status (SLUMS) examination. This tool was developed as an alternative to the MMSE because of its high sensitivity and effectiveness. Apart from the MMSE conducted yesterday evening, I will use SLUMS to test for orientation, memory, and other features that can indicate dementia. SLUMS is useful in detecting mild cognitive problems and can easily identify dementia in its early stages compared to MMSE and other tools.

Hamilton Rating Scale for Depression (HDRS). In addition to the GDS, I will use HDRS to further evaluate Eva’s mood and severity of depression. The tool has been used in various studies to further evaluate patients already diagnosed with depression (Rohan et al., 2016). Its unstructured format enables clinicians to elicit responses that cannot be observed in tools like GDS.

Cumulative Illness Rating Scale- Geriatric (CIRS-G). This tool is used to quantify the burden of disease in elderly patients aged 65 years and older. It can be used to predict the medical outcomes of patients such as long-term mortality and readmissions (Osborn et al., 2017). Eva is a patient suffering from other medical conditions like Alzheimer’s and has a history of osteoarthritis. It will be important to understand expected outcomes and plan how to improve Eva’s quality of life.

  1. What medications would you start? Please include the rationale for each medication you chose and starting dose, medication education, side effects, and any special considerations.

The pharmacological management of dementia is associated with challenges including complexities in clinical presentation and lack of therapeutic agents with robust effectiveness. The current options serve to address symptoms observed after a comprehensive evaluation of the patient.

Antidepressants. The use of antidepressants in dementia accompanied by depressive symptoms is widespread. Eva presents with depressive symptoms like helplessness and hopelessness that can be managed with medication. Additionally, her Geriatric Depression Scale is positive for depression that requires the use of medication. I will prefer to start the patient on Mirtazapine (Remeron) 15mg taken orally once daily for 1 to 2 weeks (Shaji et al., 2018). I will then increase the dosage gradually to a maximum of 45mg if well tolerated. Mirtazapine can have side effects like restlessness, racing thoughts, insomnia, and dry mouth that should be monitored.

Mood stabilizers. Mood stabilizers can be used to control symptoms of agitation, aggression, and manic-like symptoms that can occur in dementia patients. Eva is observed to experience sundown syndrome that presents with agitation, confrontation, and manic-like symptoms like hitting objects. I will prescribe divalproex sodium 125 mg twice daily and increase the dosage to 500mg twice daily if well tolerated after two weeks (Shaji et al., 2018). Side effects that may be observed include headache, weight gain, and stomach pain.

Acetylcholinesterase inhibitors. Patients with dementia usually exhibit chemical changes in the brain that alters brain function. Acetylcholine is among the neurotransmitters that are depleted leading to the inability of an individual to think and function clearly (Arvanitakis et al., 2019). To address this challenge, I will opt to continue with galantamine but decrease the dosage to 8mg taken once daily for 4 weeks (Shaji et al., 2018). I will then increase the dosage after 4 weeks to a maximum of 24mg if well tolerated. This drug can be used in all stages of dementia and has side effects including nausea, vomiting, anorexia, and weight loss.

  1. What are the steps to get her placed into a different nursing home? Please remember that she has a history of aggressive behavior and note that she has Medicare.

Step 1: The first step will involve the selection of an appropriate nursing home based on the patient/family preference and quality of care. Using tools like Hospital Compare can aid in identifying facilities with the best care for the elderly.

Step 2: The second step will involve writing an application to the facility regarding the transfer. I will complete the patient review instrument (PRI) to determine whether the patient is eligible for skilled nursing home placement and ask the admitting staff to send the review to the selected facility. The facility should be informed about the patient’s aggressive behavior and accept to have adequate resources to effectively manage the patient.

Step 3: This step will involve the transfer of the primary (Medicare) insurance to the new facility which is not a complex process. The patient will also need to transfer the secondary insurance that covers supplemental costs and services.

Step 4: The last step will involve the communication of the transfer between the two facilities through the administration. The process can be effectively done by hiring an ambulette to provide transport to the new facility.

  1. What resources and education would you give her family?

I will start by informing the family about the national and local associations available to support patients with dementia. An example is the Alzheimer’s Association and the National Institute of Aging Information center. Health education for the family will focus on the aspects of hygiene, feeding, and functional mobility. The family should be educated about signs of worsening disease like increased agitation, hallucinations, and depressive symptoms that may be observed later (Arvanitakis et al., 2019). To address the sundown syndrome observed in the patient, the family will be educated on maintaining calm environments in the evening, keeping curtains drawn to avoid changes in light, and setting and maintaining a daily routine to keep Eva oriented.

References

Arvanitakis, Z., Shah, R. C., & Bennett, D. A. (2019). Diagnosis and Management of Dementia: Review. JAMA, 322(16), 1589–1599. https://doi.org/10.1001/jama.2019.4782

Canevelli, M., Valletta, M., Trebbastoni, A., Sarli, G., D’Antonio, F., Tariciotti, L., de Lena, C., & Bruno, G. (2016). Sundowning in dementia: Clinical relevance, pathophysiological determinants, and therapeutic approaches. Frontiers in Medicine, 3, 73. https://doi.org/10.3389/fmed.2016.00073

Osborn, K., Nothelle, S., Slaven, J. E., Montz, K., Hui, S., & Torqe, A. M. (2017). Cumulative illness rating scale (CIRS) can be used to predict hospital outcomes in older adults. J. Geriatr. Med. Gerontol, 3, 30. doi.org/10.23937/2469-5858/1510030

Rohan, K. J., Rough, J. N., Evans, M., Ho, S. Y., Meyerhoff, J., Roberts, L. M., & Vacek, P. M. (2016). A protocol for the Hamilton Rating Scale for Depression: Item scoring rules, Rater training, and outcome accuracy with data on its application in a clinical trial. Journal of Affective Disorders, 200, 111–118. https://doi.org/10.1016/j.jad.2016.01.051

Shaji, K. S., Sivakumar, P. T., Rao, G. P., & Paul, N. (2018). Clinical practice guidelines for management of dementia. Indian Journal of Psychiatry, 60(Suppl 3), S312–S328. https://doi.org/10.4103/0019-5545.224472

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