How to solve a psychiatric nursing Case Study: Rose Lee Strom

How to solve a psychiatric nursing Case Study: Rose Lee Strom

Questions: From your perspective as Rose Lee’s psychiatric nurse practitioner, answer the following questions in a four page double-spaced paper (not including the reference page) in APA (7th edition) format. Include at least three peer-reviewed, evidence-based references.

1. Identify three differential diagnoses (one medical and two psychiatric) for Rose Lee. What is your provisional diagnosis for her?

2. How can you differentiate normal age-related decline from pathological signs and symptoms associated with neurocognitive disorders?

3. Rose Lee needs formal screening and/or testing. What screening tools and testing would you have her complete?

4. What medication(s) would you start her on, if any? Why? Include the name (generic and brand), dose, route, and frequency/timing for all medications.

5. What education would you provide Rose Lee and Robert?

6. What referral(s) would you give Rose Lee? Why?

SOLUTION TO THE CASE STUDY

  1. Identify three differential diagnoses (one medical and two psychiatric) for Rose Lee. What is your provisional diagnosis for her?

Rose Lee is a 73-year-old woman brought in for a psychological evaluation because of three-year history of memory impairment. Throughout the assessment, she is unable to recall her birthday and has lost track of time because she appears to be living in the era of President John F. Kennedy. Additionally, she is unable to identify objects correctly and has difficulty pronouncing simple words. The following differential diagnoses can represent Rose Lee’s condition.

Delusional Disorder. Delusional disorder is an illness characterized by at least one month of delusions without the presence of other psychotic symptoms. Individuals usually have false beliefs based on incorrect inference about external reality despite the evidence to the contrary (American Psychiatric Association, 2013). Rose Lee appears to be living in her own world and believes that tomorrow is her birthday that will be attended by key figures like the president. Additionally, she demonstrates a lack of insight because she has no complaints about her decline in housekeeping and financial affairs.

Hypothyroidism. Hypothyroidism is a condition where the thyroid does not produce enough thyroid hormone leading to confusion among other symptoms (Sakata & Okumura, 2018). The condition is common among post-menopausal women aged 60 years and above. The condition is associated with cognitive issues like increased forgetfulness, mental slowing, and brain fog. Rose Lee presents with confusion and has speech problems that could be associated with hypothyroidism.

Provisional diagnosis. The third and most likely diagnosis for Rose is Alzheimer’s dementia. Dementia is a syndrome that is characterized by a progressive neurocognitive decline of sufficient magnitude to interfere with normal functioning. The prevalence of this condition is about 5% to 7% among adults aged 60 years and older with Alzheimer’s disease accounting for more than 90% of cases for adults above 70 years (American Psychiatric Association, 2013). Patients with this condition demonstrate a decline in levels of functioning and performance, diminished ability to function at work, impaired ability to remember information, spatial cognitive deficits including object agnosia, and word-finding deficits. Rose Lee demonstrates a decline in normal functioning like housekeeping and financial affairs, has difficulty finding words, and her amnestic presentation indicates she might be having Alzheimer’s dementia.

  1. How can you differentiate normal age-related decline from pathological signs and symptoms associated with neurocognitive disorders?

Cognition is critical for functional independence and its decline with aging leads to the inability to live independently, manage finances and perform other tasks. During aging, both sensory perception and processing decline with more than 70% of individuals demonstrating hearing problems (Arvanitakis et al., 2019). The attention that involves the ability to focus on specific information declines and the elderly are only able to focus on simple attention tasks like digit span. Some aspects of memory remain intact during aging while others like retrieval of newly learned material become difficult. Historical events remain intact for most individuals but the ability to retrieve and accuracy of the information becomes affected. Regarding speech and language, the elderly can be able to communicate well, demonstrate verbal reasoning, and use vocabulary. However, verbal fluency, retrieval, and confrontational naming decline with issues like repetition and declined specificity in word choice observed.

While some mild changes in cognition are observed during normal aging, pathological signs present differently during aging. The decline in cognition becomes more severe and may include things like rapid forgetfulness, difficulty solving common problems and expressing oneself during conversations. The progression of these symptoms can also differentiate normal from abnormal aging cognitive changes. For example, patients with dementia demonstrate accelerated cognitive decline whereby within 3 years the majority of the elderly lose independence to perform tasks (Arvanitakis et al., 2019). Independent living should not be compromised during normal aging, unlike transitions to neurodegenerative conditions.

  1. Rose Lee needs formal screening and/or testing. What screening tools and testing would you have her complete?

Mini-mental state examination (MMSE). MMSE is a tool used to measure cognitive impairment in older adults. It can be used to estimate the severity of the impairment and follow the course of treatment (Arvanitakis et al., 2019). I will use this tool to assess for cognitive changes in Rose because it assesses for cognitive changes in attention, language, memory, orientation, and visual-spatial proficiency. MMSE is scored on a scale of 0-30 with scores above 25 interpreted as normal cognitive status. A score of 0-17 indicates severe impairment while 18-23 indicates mild impairment.

Thyroid function test (TFT). Because the symptoms portrayed can be consistent with hypothyroidism, a thyroid function test will be required. I will look at the levels of thyroid-stimulating hormone (TSH) and thyroxine (T4) in the blood to detect any abnormalities (Sakata & Okumura, 2018). TFT is a recommended test in individuals with dementia, especially before prescription of medication because underdiagnosis could lead to ineffective management.

  1. What medication(s) would you start her on, if any? Why? Include the name (generic and brand), dose, route, and frequency/timing for all medications.

The first choice for the management of the patients is Galantamine (Razadyne). Galantamine is a drug under the class of acetylcholinesterase inhibitors used to manage mild to moderate dementia in patients with Alzheimer’s disease. I will prescribe galantamine 8 mg taken orally once daily for the first four weeks (Arvanitakis et al., 2019). I will then increase the dosage gradually every month to a maximum of 24 mg if well tolerated by the patient. I will also prescribe Memantine (Namenda) 5mg taken orally once daily for two weeks and then increase the dosage by 5mg to a maximum of 20 mg per day (Arvanitakis et al., 2019). The drug is well-tolerated and often used with acetylcholinesterase inhibitors to manage dementia.

  1. What education would you provide Rose Lee and Robert?

The first aspect I will consider for Rose and Robert is education about dementia and its long-term management. I will explain how the disease causes cognitive impairment and other symptoms like the inability to perform tasks that might occur later. Secondly, I will explain the importance of medication adherence to slow down cognitive impairment. I will educate Robert to ensure Rose has adequate family support, especially now that her husband passed away. I will inform both parties about available local and national resources like the Alzheimer’s Association and the National Institute of Aging Information center which could be important during disease management.

  1. What referral(s) would you give Rose Lee? Why?

Most patients with dementia are faced with the challenge of unmet needs from primary care physicians and referral for special care is among the available options. I would refer Rose to Alzheimer’s Association chapters to ensure she can receive adequate support following her new diagnosis. This association is available to provide linkage to community-based services that can aid to promote adjustment and fight the stigma that comes with the diagnosis of dementia.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Washington, DC.

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

Sakata, N., & Okumura, Y. (2018). Thyroid function tests before prescribing anti-dementia drugs: A retrospective observational study. Clinical Interventions in Aging, 13, 1219–1223. https://doi.org/10.2147/CIA.S168182

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