NU-664B Week 8 Discussion 1: Memory Loss

Value: 100 points

Due: Create your initial post on Day 3, Initial Response post by Day 5, and Reflective Response by Day 7.

Gradebook Category: Simulated OV Discussions

Instructions

Prior to completing this first discussion forum, please watch the Discussion Board Directions video for more information on how to complete the forums.

Initial Post

You are the nurse practitioner in family practice. You are seeing a new patient today: a 70-year-old African American woman, Selah, who is accompanied by her daughter, Britt, to the appointment. The PMH of the patient includes HTN, DM, Hyperlipidemia, TIA × 2, and Osteoarthritis of both knees, with multiple falls resulting in two diagnosed concussions. The daughter is concerned because she feels as if her mother’s memory isn’t what it used to be. Britt states that her mother sometimes misplaces things and forgets events, as well as the names of people she has known for a long period of time.

Helpful hint: Don’t forget to ask OLDCARTS for each condition and about medication.

Complete the following:

Initial Post by Wednesday (Day 3) at 11:59 p.m.

• List 10–20 questions of subjective information that your patient will need to provide to help you formulate your differential diagnoses and plan. Include two scholarly references for the questions that you ask of your patient. See the Grading Rubric for more detail.

Initial Response Post by Friday (Day 5) 11:59 p.m. Choose a classmate’s questions to answer:

• Every peer post should only have one response post. Please do not reply to a peer if a response is already posted.
• You are answering as the patient. Make it case appropriate but imaginative. Be creative and answer thoroughly. No references are needed.

Reply Posts

Reflective Response Post by Sunday (Day 7). Please respond with the following:

• Four appropriate differential diagnoses and rationales with references. For each differential diagnosis, explain why this is an appropriate differential and how it was/would be ruled in or out. Support your answers with references.
• Pick one differential and create a plan of care for that patient.
  • Plans must include Pharmacology, Non-Pharmacology, Labs/Diagnostics, Referrals/Interprofessional Communications, Patient Education (10–15 individual items minimum) and follow up.
  • Make sure to pick one health maintenance item for this patient (primary or secondary) and explain to the patient why this is important.
  • Address one social determinant of the health this patient may face during your visit. How will you help the patient overcome this obstacle to health care?

Please refer to the Grading Rubric for details on how this activity will be graded.

Posting to the Discussion Forum

1. Select the appropriate Thread.
2. Select Reply.
3. Create your post.
4. Select Post to Forum.

Week 8 – Discussion Board Response

HPI: 70-year-old African American woman, Selah, who is accompanied by her daughter, Britt, to the appointment. The PMH of the patient includes HTN, DM, Hyperlipidemia, TIA × 2, and Osteoarthritis of both knees, with multiple falls resulting in two diagnosed concussions. The daughter is concerned because she feels as if her mother’s memory isn’t what it used to be. Britt states that her mother sometimes misplaces things and forgets events, as well as the names of people she has known for a long period of time.

Differential Diagnoses

1. Alzheimer’s Disease. AD has an insidious and progressive onset for symptoms (Dunphy et al., 2019). Common signs of the onset of disease are seen by family members who start noticing changes over time. Cognitive decline often seen in AD patients are an inability to learn new information or recall things they knew previously, aphasia, apraxia, agnosia, and weaknesses with executive function (Dunphy et al., 2019). This patient is displaying signs of learning and memory deficits. She is having issues with misplacing familiar items and forgets events, and names of people she knows well. These are all signs for further assessment of AD (Dunphy et al., 2019).

2. Depression. Symptoms of depression can mimic AD (Dunphy et al., 2019). Once older adults have multiple falls, they can be fearful of falling again (Kiel, 2022). Fears of falling are associated with depression as well as cognitive impairments (Kiel, 2022). Increased depression can be a sign of increasing dementia with AD (Dunphy et al., 2019).

3. Head Injury. Head injuries are a risk factor for Alzheimer’s disease (Dunphy et al., 2019). She takes two antihypertensive medications, an opioid for pain, and a blood thinner. Antihypertensive medications should be closely monitored in older adults due to the increased risk for falls (Kiel, 2022). I would want to check PT/PTT and platelets as well as a head CT to ensure she does not have any intracranial bleeding.

4. Drug-related dementia. Opioids can negatively affect cognitive function in older adults (Dunphy et al., 2019). However, this can be ruled out in this patient because she was prescribed pain meds a couple of months ago, and her daughter states her memory issues started 6 months ago. Another drug to be weary of is the Plavix. This is a blood thinner and she has two recent falls.

Final Diagnosis: Alzheimer’s Disease

Pharmacology

• Donepezil (Aricept) (Dunphy et al., 2019).
• Vitamin E (Dunphy et al., 2019)

Non-Pharmacology

• Keeping a Routine
• Memory training
• Daily exercise
• Good nutrition/hydration
• Keeping up with preventative care (Dunphy et al., 2019).

Labs/Diagnostics

• CBC, CMP, serum Ca, TSH, FT4, Vitamin B12, UA, non-contrast CT brain (to rule out any surgically treatable lesions or vascular disease), PET scan (detect amyloid deposits) (Dunphy et al., 2019).

Referrals

• Memory disorder center
• Neurology for PET scan and evaluation
• Social services (Dunphy et al., 2019).

Patient Education

• Use memory aids and modify the environment at home so that her independent functioning can be maximized. By this I mean, declutter the house, make sure she uses proper footwear to avoid falls, keep important things she uses all the time out in the open where it can easily be found, etc. (Dunphy et al., 2019).
• Stick to routine. The more familiar her day to day is, the longer her cognitive function will remain intact (Dunphy et al., 2019).
• You can practice memory training to help with recall (Dunphy et al., 2019).
• Exercise and enroll in recreation activities she would enjoy to help with socialization (Dunphy et al., 2019).
• Have discussions about legal and financial issues related to decisions she is able to make and ones that should be left to someone she trusts, this includes end-of-life decisions (Dunphy et al., 2019).
• Be sure to keep a closer eye on her; memory issues can be dangerous if she starts to wander and cannot remember where she is (Dunphy et al., 2019).
• Donepezil (Aricept) common side effects are nausea, diarrhea, anorexia, and weight loss. We will monitor her liver function on this medication (Dunphy et al., 2019).
• Donepezil does not prevent progression of AD, but can slow the rate of decline in cognitive function (Dunphy et al., 2019).
• Donepezil reaches its therapeutic level with consistent administration. This means that she should not start and stop this medication as it will not allow her to reach the level of function she had before stopping the medication (Dunphy et al., 2019).
• Make sure she is eating a well- balanced diet (Dunphy et al., 2019).

Follow-up

• Placed referral to memory disorder center. This will give you resources which are multidisciplinary, to include counseling and support groups. These can be beneficial for your mother and you as her caregiver (Dunphy et al., 2019).
• Follow-up with social services so that an evaluation can be done for yours and her needs at home (Dunphy et al., 2019).
• Follow-up by returning to the clinic or urgent care if you notice aggressive changes in her behavior, increased depression, or changes involving loss of functional daily living (incontinence) or anything that may require more assistance from services or medical providers (Dunphy et al., 2019).

References Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care: The Art and Science of Advanced Practice Nursing-An Interprofessional Approach. (5th ed.). F.A. Davis.

Kiel, D. P. (2022). Falls in older persons: Risk factors and patient evaluation. UpToDate. Retrieved from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/falls-in-older-persons-risk-factors-and-patient-evaluation?search=Falls%20on%20blood%20thinners&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H3

Questions specific to patient

1. Can you tell me your name? Do you know where you are? Do you know the date today?

2. Do you notice problems with your memory? If so, can you provide specific examples?

Question specific to daughter

3. Could you please provide more specific examples of your concern with her memory problems? Is it short term or long-term memory you notice being affected?  

4.  How long have you noticed problems with your mothers memory? Is there any relationship to the concussions? Was there a problem before the concussions or only after?

Questions open to the room either patient or daughter

5. Do you feel that the memory is worsening? Has it been sudden or gradual?

 6. When were the falls?

7. Were you seen in the hospital after the falls? Did they do imaging? Do you have the reports?

8. Are you taking any medications, supplements, or vitamins either prescription or over the counter? Are any of these medications or supplements new or recent dosage increases?

9. Do you drink alcohol or use any recreational drugs?

10. Any vision changes? Blurred vision? Loss of vision? Visual loss?

11. Any hearing problems?

12. Any change in sleep patterns?

13. Any signs of infection? Fever? Cough? Abdominal pain? Diarrhea? Problems with urination?

14.Any hallucinations? Seeing, hearing, or feeling things that are not there? Any tremors?

15.Any change in sleep pattern?

16.Do you live with anyone?

17.Do you drive? Do you have any problems with that?

18.Do you have any problems with completing activities of daily living? Washing, dressing, cooking ( ex. leaving stove on), managing finances? Or do you have help with these?

19.Do you have headaches? If so how often and what is the location?

20. Are you feeling depressed? Or any personality changes?

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and

                clinical diagnosis in primary care. St. louis, MO: Elsevier mosby.

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary                 Care (5th ed.). F. A. Davis Company.