Old Male Patient Has Got Admitted In Hospital

Old Male Patient Has Got Admitted In Hospital

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Old Male Patient Has Got Admitted In Hospital

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Old Male Patient Has Got Admitted In Hospital

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Mr. Donald John, 81 years old male patient has got admitted in the hospital B side on 10.01.2017 in room no: 261. His feelings, self- esteem and perception level was assessed. He has past history of moderate dementia because of transient ischemic attack and is suspected to have Alzheimer’s disease since 2014. He also had hyponatraemia secondary to dehydration, low mood, anxiety, hypercholesterolemia, Ischemic heart disease with anterior MI, moderate left anterior descending lesion and stenosis of circumflex. He was an engineer and lives with his wife in his village. During history collection, he was found to have difficulty in expressing emotions and inability to write but has good reading skills. He has feelings of inferiority and is reluctant to interact with others due to his disabilities. He has feelings of unworthiness and lack of meaning for his life. His wife is his full support and his one son and one daughter rarely visits him. 
Mr. John is diagnosed to have dementia which is a condition in which there can be a gradual deterioration of memory, judgment, language, other cognitive abilities and/or sensorial skills along with orientation to time, place as well as person that declines an individual’s ability to participate in daily activities. Dementia develops if any changes or damages occur in the brain (Hinkle, 2014). The important cause of dementia involves brain diseases in which the neurons of brain degenerates and destroys quickly as compared to that of normal ageing. Mr. John has Alzheimer’s disease (a type of neurodegenerative disorder) which is a type of dementia. It is responsible for 2/3rds of dementia in elderly as in Mr. John. In Alzheimer’s disease (AD), the degeneration of brain cells leads to shrinkage of brain especially cerebral cortex, which is the grey matter layer that covers the brain and hypothalamus (Linda, 2011). This grey matter functions in processing of thought as well as many complex brain functions that includes storing memories, retrieval of memories, mathematics-calculation, spelling the words, planning and organizing.
Clumps of abnormal protein fragments (beta-amyloid) called as ‘plaques’ or twisted protein strands (tau) ‘tangles’ slowly develops and deposits in the brain, which are responsible for increased loss of brain cells (NHS, 2014). This can cause loss of connection between brain cells and reduce the production of neurotransmitters that are needed to relay impulses from one neuron to another. Moreover, Acetylcholine that is responsible for certain activities that are associated with learning skills, attention abilities and memory capacity (Lewis, 2013, Aminoff, 2016). People having Alzheimer’s disease can feature with decreased acetylcholine production in the brain along with production of glutamate that is much needed for connecting between brain-neurons are also reduced causing trouble in learning and long-term memory (Jurczak, 2014, NHS, 2015). As dementia progresses, the degeneration of neurons spread affecting the neurons of remaining brain parts. Alzheimer’s disease, ischemic stroke, low self-esteem, reserved personality and cardiac diseases of Mr. John has contributed to progression of dementia to its moderate stage (Zhang, 2014, Fairfax, 2014). 
Alzheimer’s disease (AD) features with slow decline in memory, thinking, reasoning as well as behavior skills that causes interference with daily activities in its severe stage. Some features of Alzheimer’s disease might be similar to that of age-related changes and other forms of dementia but the differential diagnosis could be made based on the a trace line difference which is discussed as follows. All the persons may encounter 1 or more of these features as they age. 1) Memory loss that affects daily activities- This is the most common feature of Alzheimer’s with loss of memory, particularly forgetting the informations that are recently learned, unable to remember important occasions, dates and/or events, repeating the words, asking the same question again and again, increased reliability on memory aids as reminder- notes and/or some electronic devices and/or relatives for activities that they were handling by their own previously as in Mr. John whereas in age- related degeneration, the persons may forgets persons’ names and/or appointments sometimes but can remember it later (Alzheimer’s Association, 2017). 2). Difficulties in planning and problem solving- Persons with AD may find difficulties in developing and following a plan/ work that requires numbers, trouble in remembering familiar food-recipes and tracking monthly bills as John suffers. They may not be able to concentrate in things and may take more time to do work than before while in age-related changes, only occasional mistakes occur while working with a checkbook. 3). Problems in completing familiar activities at home or working place or at leisure time- AD persons often find difficulty in completing daily activities. They may have trouble in driving to a well-known place, checking budgets and remembering game rules whereas in senile degeneration, occasional help may be needed to change the microwave settings and/or recording a TV show which is evidenced in Mr. John (McKhann, 2011).
4). Confusing with time and/or place- AD people may not be able to track the dates or seasons, difficulty in understanding things that has not occurred at present and forgetting the place where they are present and how they came there which is similar to Mr. John (McKhann, 2011). In senile degeneration, older person may confuse with the day of the week but trace it out after. 5). Difficulty in understanding visual images with spatial relationships- Having vision problem is a feature of AD as Mr. John. These persons may have trouble reading, differentiating colors or judging distance that can create problems in driving. But in ageing-related changes, the vision changes occur due to cataracts or senile degeneration (Alzheimer’s Association, 2017). 6). Troubles with speaking words and/ or writing- AD people may have difficulty in conversing with others; may stop in between conversation and/or trouble in continuing conversation or may repeat words within themselves as like John (McKhann, 2011). AD people may have trouble with vocabulary, selecting right words or naming the things wrongly while trouble occurs only in finding the correct words in age-related changes.
7). Misplacing items with trouble in re-tracing steps- AD people may have difficulty in keeping things in correct places, losing things and inability to go back through steps again and may abuse others. In contrast, people with senile degeneration may misplace things and find trouble with retracing at few times. 8). Poor or impaired judgment- AD people may have poor judgment and/or decision-making process and may pay less attention in self-care activities whereas making bad decision is common in age-related changes. 9). Withdrawal from activities- AD persons may withdraw from routine activities, hobbies, sports, social activities, etc and feels isolated which is similar to Mr. John with feelings of isolation while in age-related changes, they may withdraw from work and familial activities at times (McKhann, 2011). 10). Mood swings and personality changes- AD persons may have confusion, suspiciousness, depression, fearfulness and/or anxiousness as like John who is depressed and confused (Alzheimer’s Association, 2017). But in a typical age-related degeneration, they may become irritable in performing daily activities.
Differential diagnosis has to be made clearly between AD and age-related alterations by comparing the signs and performing appropriate diagnostic examinations (Table-1). The features of diseases other than AD that can cause confusion in thinking, difficulty in focusing on things, loss of memory includes iron-deficiency anemia, diabetes-mellitus, renal disorders, liver diseases, infection, some vitamin deficiencies, thyroid disorders and cardiac, lung and blood- vessel abnormalities (Alzheimer’s Association, 2017, Albert, 2011).
There is no any single test to confirm the diagnosis of AD. A complete diagnosis should be made by performing clear assessment by considering all the causes. The first step involves collecting medical history with past illnesses and medicine history with family history of AD. Mr. John had transient ischemic attack with suspected Alzheimer’s disease, depressiveness and anxiousness which suggests that the patient has developed moderate dementia because of AD and its medications. There is a family history of AD with dementia in his father who has died at 81 years of age (Lewis, 2013). Physical examination was performed to rule out diet pattern, alcohol intake, and use of drugs (current, over-the counter medications & supplements), vital signs, heart sounds and general assessment. His examination shows that he has trouble in letting emotions with difficulty in writing but not in reading (Alzheimer’s Association, 2017). He has forgetting, repeatedly asks questions, short-temperedness, isolated and boredom feelings, performing activities repeatedly, wanders with-out purpose, aggressiveness, abusing others, shouting, beating, screaming, agitation, depressive features as trouble ventilating his emotions, poor judgmental capacity, lack of self- control with self- esteem, suspiciousness which makes Mr. John to be anxious, with-drawn, low-mood, confused, lost and frustrated (NHS, 2014).
Genetic test may be performed to trace out APOE-e4 and autosomal- dominant AD gene which is not performed in John. Neurological exam was performed carefully to rule out conditions that may indicate brain diseases other than AD as smaller/ large stroke, brain tumors, hydrocephalus, Parkinson’s disease or other disorders which can cause memory/ thinking impairment (Sperling, 2011, Alzheimer’s Association, 2017). Reflexes, coordination of movements, muscle tone as well as strength, eye movement, speech and sensation were assessed in Mr. John which shows that his movements were not coordinated due to poor muscle strength whereas his speech and sensation remained intact (Hinkle, 2014). His mental status examination shows that his memory is impaired and is unable to solve problems with poor thinking skills. He has trouble in saying the date, place and time; remembers words and follows instructions very slowly and unable to perform simple calculations. The Mini-mental status examination score of John is assessed to be 15 which suggest that he has moderate dementia. Mini-cog tests by asking him to recall and repeat things after few minutes of 3 common things were performed in which he was able to recall one objects name only after 3 minutes whereas he was unable to recall other 2 objects name (Jack, 2011). His CT exam shows that he has areas of transient ischemic attack with stenosis in circumflex of brain. Mood assessment shows that he is withdrawn, depressed, anxious, isolated with absence of interest in life.
Dementia can lead to varied difficulties in cognition as memory loss, learning difficulties, poor thinking, poor judgment, language with praxic functioning difficulties, decreased psycho-motor speed, and poor problem- solving abilities. Behavioral problems involves self- care deterioration, trouble communications, lapse in speech, absence of clarity, hallucination with delusional thoughts, alterations in gait with balance (NHS, 2014). Emotional problems includes dis-regulated with poorly organized behavior, apathy, energy loss, unwilling to work, delayed thinking, agitation, neglect, paranoia, with mood swings (DH, 2012). The trouble arises based on the shrinkage in the brain lobe. If frontal lobe is involved, the person’s self and others awareness are affected as in Mr. John whereas if parietal lobe is affected, the language with speech-comprehension, vision as well as meaning of objects can be impaired. When temporal lobe is damaged, short and long- term memories will be impaired and memory fades when the damage moves deep into brain areas. Mr. John is on Tab. Risperidone- 500 mg to control his agitation and schizophrenic features. It is a Benzisoxazole derivative which is an antipsychotic medicine that has higher affinity on 5-hydrotryptamine as well as dopamine receptors. Risperidone is mainly for managing schizophrenia, behavior alteration in John with dementia and mood swings (depression) (Galbraith, 2015).
The features of John suggest that he is in moderate stage of dementia as forgetfulness, more marked changes, requires more support for daily activities, highly aggressive, gets upset easily, anger, difficulty performing activities, low mood, withdrawn, inability to recall address, names, etc, confusion, needs help for choosing clothes, difficulty to control bladder and bowels, alterations in sleep patterns, personality with behavioral changes (suspiciousness, repetitive behaviors as wringing hands/ tissue-shredding) ((McKhann, 2011, DH, 2012).
Mr. John requires a structured physical, mental, emotional, societal, cognitional, sexual as well as spiritual care by social-care specialists that is rendered in aged-care homes. The treatment for John should be provided in stages so as to promote the quality care. Firstly, they will evaluate the reasons for his altered behavior. The workers in aged-care home will establish rapport with him and his family (NHS, 2015). In aged-care homes, they will refer to psychiatrists to evaluate his mental problems, counselors to give individual and family counseling, clinicians to manage his medical issues, staff-nurses to meet his personal-needs and occupational-therapists to make John to perform simpler activities. In aged homes, the societal workers will be assessing, counseling, communicating, caring, supporting and guiding John by developing a framework of management and will be managed accordingly.
The nurses have to clearly diagnose the stage of patient by comparing it with diagnostic criteria. She should assess his background, history, likes/ dislikes; capacities and abilities to plan interventions. Nurses should provide person- centered care which involves caring persons at the centre of other care rendered based on his needs, wishes, believes and preferences. This person- centered care can minimize agitated feelings in John. This approach involves valuing him, giving respect, enabling social relationships and choices, giving opportunities to John to stimulate him, recognize as well as consider him as a whole (NHS, 2015). Nurses should identify John’s needs and plan for supportive care based on his preferences. Nurses should meet his daily needs, support him to perform elimination and provide diversion activities. Non- personal-centered care can also be given by dictating the care-needs to his wife by considering his needs. John can be referred to support workers who focus on his skills with abilities rather than the skills he has lost. Strategic plans can be developed based on his disabilities as urinary & bowel incontinence, anxiety, depression, agitation, repetitive words, etc (Gray, 2013).
The history of John indicates that he has depression because of his ageing process and Alzheimer’s disease. His disabilities have affected his self- identity; respect, and esteem which have developed negative thoughts in him (Orth, 2012). On examination, he assessed to have inability to express his feelings and write. He has inferior feelings and feels hesitant to mingle with others because of his disabilities. He looks to have low mood, anxious, isolated and withdrawn. He expresses that he is worthless, hopeless and there is no meaning for his life. His modified behavior may lead to inability to express his needs that may again stimulate frustration in John expressing with challenging- behavior. AD is found to interfere with the regulation of neurotransmitter which affects the mood (begins at the early stage of AD development) and hence it leads to the development of depression (Ellison, 2016).
Moreover, damage/ error theories suggest that presence of chronic diseases such as hypertension, ischemic stroke, cardiac diseases, etc contributes to depression development which is similar to John (Jin, 2010). The disabilities that are caused by his multiple disorders has increased his feelings of stress that made him dependent on his wife for support which has lead to worthless, hopeless feelings and insomnia resulting in depressiveness. Even, the disengagement theory suggests that as the person ages, he starts to withdraw and isolate himself from interaction with society that causes decline of continuity in daily activities causing physical with psychological changes as in John. The immunological theory adds that as the person ages, the functions of immunology declines slowly resulting in Alzheimer’s disease, cardiac diseases, etc leading to depressive ideas as John experiences.
Depressive features increases and takes a different quality, as AD intensifies. Apathy commonly occurs when the depressive features emerges in the moderate stage of AD with classic symptoms that includes feelings of agitation, withdrawn, weeping, difficulty in expressing feelings of joy (anhedonia), lack of appetite, severe hallucinations, suicidal thoughts and psychotic delusions which is evident in Mr. John with these features. When the neuro and cognitive impairment intensifies to a more severe stage, the affected persons may not able to remember depressive symptoms and/or to clearly understand or articulate its meaning (Ellison, 2016). In the severe stage of dementia, the unwanted disruptive behaviors that include resisting for getting care, expressing delusive feelings or showing increased agitation behavior and sometimes self- destructing behaviors will provide cue for developing depression. Though these are not evident in Mr. John, he should be closely observed for these features to handle it at the earliest. Thus, adequate treatment and proper care can delay the progression of dementia and its related feature.
Albert, M.S et al. (2011). The diagnosis of mild cognitive impairment due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease: Alzheimer’s Dementia. 7:270–9
Alzheimer’s Association. (2017). 10 Early Signs and Symptoms of Alzheimer’s. Retrieved from https://alz.org/10-signs-symptoms-alzheimers-dementia.asp
Aminoff, J.F et al. (2016). Handbook of Clinical Neurology. London: Elsevier
Department of Health- DH. (2012). Caring for our future: Reforming care and support (White paper) Norwich: The stationary office.
Ellison, J.M. (2016). Depression and Alzheimer’s disease. Retrieved from https://www.brightfocus.org/alzheimers/article/depression-and-alzheimers-disease
Fairfax, C.N. (2014). Social Work, Marriage, and Ethnicity: Policy and Practice: J Human Behav Soc. Environ. 24:83-91. Retrieved from https://www.researchgate.net/…/272123480_Social_Work_Marriage_and_Ethnicity_Poli…
Galbraith, A., Bullock, S. & ‎Manias, E. (2015). Fundamentals of Pharmacology: An Applied Approach for Nursing and Health. Retrieved from https://books.google.co.in/books?isbn=1317325877
Gray. (2013). Transforming adult social care. Retrieved from https://books.google.co.in/books?id=p0UbAgAAQBAJ&pg=PA232&lpg=PA232&dq=
Hinkle, J.L. (2014). Brunner’s and Suddarth’s Textbook of Medical Surgical Nursing. (13th ed.). Philadelphia: Lippincott Williams and Wilkins.
Jack, C.R et al. (2011). Introduction to the recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease: Alzheimer’s Dement. 7:257–62. 
Jin, K. (2010). Modern Biological Theories of Aging: Aging Dis. 1(2): 72–74. Retrieved from https://www.ncbi.nlm.nih.gov › NCBI › Literature › PubMed Central (PMC)
Jurczak, W., Porzych, K & Polak-Szabela, A. (2014). Nurse’s Role In Taking Care Of A Patient With Alzheimer’s Disease: Medical and Biological Sciences. 28(2): 5-10. doi: https://dx.doi.org/10.12775/MBS.2014.014
Lewis, S.M., Heitkemper, M. M., & Dirksen, S.R. (2013). Medical Surgical Nursing: Assessment and Management of Clinical Problems. (9th ed.). Missouri: Mosby.
Linda, C et al. (2011). Alzheimer’s Disease. Retrieved from https://books.google.co.in/books?isbn=0313381100
McKhann, G.Y. (2011). The diagnosis of dementia due to Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease: Alzheimer’s Dementia. 7Answer(3): 263–269. doi:  10.1016/j.jalz.2011.03.005
NHS. (2014). Dementia guide. Retrieved from https://www.nhs.uk/Conditions/dementia-guide/Pages/dementia-behaviour.aspx
NHS. (2015). Dealing with challenging behavior. Retrieved from https://www.nhs.uk/Conditions/social-care-and-support-guide/Pages/challenging-behaviour-carers.aspx
Orth, U. (2012). Life-span development of self-esteem and its effects on important life outcomes: J PersSocPsychol. 102: 1271-1288. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/21942279
Sperling, R.A et al. (2011). Towards defining the preclinical stages of Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease: Alzheimer’s Dement. 7:280–92
Zhang, L. (2014). Self-esteem as mediator and moderator of the relationship between stigma perception and social alienation of Chinese adults with disability: Disabil Health J. 7: 119-123. Retrieved from https://europepmc.org/abstract/med/24411516

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