PATHOPHYSIOLOGY NR 507 WK7 TD2

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Week 7: Behavioral, Neurologic, and Digestive Disorders Discussion Part Two Loading... Loading... Discussion Discussion Part Two (graded) Your patient is a 77-year-old woman who has been more socia ... lly withdrawn lately and told her daughter she had not been feeling well. Her daughter has noticed a stepwise decline. While shopping for groceries with her daughter she became separated from daughter in the aisles. She became confused and angry when store employees and others tried to assist her. Her current medications are Hydrochlorothiazide, Lisinopril and Atorvastatin. • What is your differential diagnosis based on the information you now have? • What other questions would you like to ask her now? (Questions can be asked of patient first, and then of reliable historian separately.) • How would you treat this patient and discuss why you give each medication or therapy you give. Responses Lorna Durfee Discussion Part Two 6/13/2016 2:50:10 PM Your patient is a 77-year-old woman who has been more socially withdrawn lately and told her daughter she had not been feeling well. Her daughter has noticed a stepwise decline. While shopping for groceries with her daughter, she became separated from daughter in the aisles. She became confused and angry when store employees and others tried to assist her. Her current medications are Hydrochlorothiazide, Lisinopril, and Atorvastatin. • What is your differential diagnosis based on the information you now have? • What other questions would you like to ask her now? (Questions can be asked of patient first, and then of reliable historian separately.) • How would you treat this patient and discuss why you give each medication or therapy you give. Doctor Brown: This patient appears to be exhibiting signs of loss of memory and having difficulty finding her way. She also demonstrates some agitation. From her symptoms and signs, she is exhibiting forgetfulness along with confusion and irritability; this could be the start of Alzheimer’s or dementia.When evaluating this patient consideration of current medications are vital. There can be drug interactions and toxic effects of certain medications. This patient may be exhibiting signs of toxic drug reaction. As we age, our body does not filter out medications as easily as when we were at a younger age. There could be a side effect or interaction occurring with her medications. As for her medications, The American Geriatrics Society, and Beers Criteria recommends that in patients over 65 years of age to use caution when prescribing diuretics. There is a risk of the syndrome of inappropriate antidiuresis, or hyponatremia when using Hydrochlorothiazide (Dynamed, 2016). This patient could be exhibiting the beginning of potassium depletion or hyponatremia. There is no indication of what her fluid consumption has been or what her electrolyte levels are. There can be adverse effects with an excessive reduction in blood pressure such as with orthostatic hypotension with the use of Hydrochlorothiazide. Confusion can be a symptom of adverse effects from the drug (Dynamed, 2016). Lisinopril – This is an ACE inhibitor and antihypertensive medication. This medication, when used in the geriatric population, needs to be used with caution. Another thing to consider, when using this medication, is decreased hepatic, renal and cardiac function. This medication can also cause hypotension (Dynamed, 2016). Atorvastatin - An HMG-CoA Reductase Inhibitor. This medication can be a factor for myopathy in the geriatric population. Before the use of this medication the adverse effects, drug interactions, and patient preferences should be reviewed. It is also an antilipemic agent. As a side effect from this medication, the patient may also be experiencing hyperglycemia effects. The side effect of cognitive impairment is rarely reported with use of this medication. Because there is a component of cognitive impairment in this patient, the National Lipid Association (NLA) statin safety assessment task force recommends evaluating this patient for a statin. They also recommend evaluation for non-statin causes, such as other medications, systemic or neuropsychiatric causes (Dynamed, 2016). What other questions would you like to ask her now? (Questions can be asked of patient first, and then of reliable historian separately.) When asking this patient questions we could begin by asking her if she is feeling confused and overwhelmed. We could use a very calm demeanor. We would ask about her eating, sleeping, bowel movements, and do a system review. If she cannot answer those questions, the caregiver who accompanies her can help with this. We would also need to do a physical exam. Then we would need to do a mini-mental exam. We could use the Folstein mini-mental questionnaire. We could ask her if she knows where she is. We could also ask if she knows the date, the time, the President, and her name. We could have her spell a “WORLD” backward. We must assess her mental status and review her medications. The family members that accompany this visit could fill us in on details of what they have observed and give a detailed history. We could run some further blood tests to determine if there is any metabolic condition underlying this change. What is your differential diagnosis based on the information you now have? I think that this patient shows signs of mild cognitive impairment and possible onset of dementia. The Alzheimer’s Association explains that dementia is not a specific disease but an overall term that outlines a range of symptoms that appear with a decline in memory or thinking. Dementia limits the person’s ability to performactivities of daily living. Alzheimer’s accounts for 60 to 80 percent of the cases of dementia, however, vascular dementia is the second most common type worse (Alzheimer's Association, 2016). There are other conditions such as thyroid or vitamin deficiencies that can cause problems. The Alzheimer’s Association lists some of the conditions under what is considered dementia. If patients have dementia at least two core mental functions must be impaired. The core mental functions are; memory, communication, and language, ability to focus and pay attention, reasoning and judgment and visual perception. There can be problems with short-term memory, paying bills, preparing meals and traveling into unknown and recognized areas. Dementias are progressive, and the symptoms can start slowly and then get worse (Alzheimer's Association, 2016). There are other problems that cause memory issues, such as; depression, medication side effects, excessive use of alcohol, thyroid and vitamin deficiencies (Alzheimer's Association, 2016). Mild cognitive impairment is a symptom first seen in the progression of Alzheimer’s Disease. There is mild memory loss for recent and new information in early stage Alzheimer’s Disease. In other words, there is short-term memory loss, difficulty with planning and disorientation to location. There is also possible depression and mild anxiety. There is also mild instrumental activities of daily living (McCance, Huether, & Brashers, 2014, p. 550). How would you treat this patient and discuss why you give each medication or therapy you give? Establishing the cause for this dementing process may be very complicated. However, patients should be evaluated with laboratory and neuropsychologic testing and brain imaging. The use of neuroleptic medications could be considered. If there is depression the use of antidepressants can be appropriate (McCance, Huether, & Brashers, 2014, p. 546). Moyer ( 2014) and The United States Preventative Task Force state that older aged people are a known risk factor for cognitive impairment. There are other risk factors such as diabetes, tobacco use, hypercholesterolemia, and hypertension. A history of head trauma, depression, and physical frailty. Also, the lack of a proper support system. The screening tests suggested are for cognitive impairment, and that includes tasks that require attention, memory, language and visual-spatial abilities. The most used method is the Mini-Mental State Examination. There is also the clock drawing test, 7-minute screen, and questionnaire on cognitive decline in the elderly. The recommended treatment with pharmacologic agents includes acetylcholinesterase inhibitors and memantine. They also recommend cognitive training, lifestyle modifications and behavioral, exercise, education and multidisciplinary care (Moyer, 2014, p. 792). The National Institute on Aging (2016) tell us that there are medications that are approved by the United States Food and Drug Administration to treat the symptoms of Alzheimer’s Disease. They are; Donepezil (Aricept), rivastigmine for mild to moderate Alzheimer’s. Aricept and Memantine (Namenda) can be used to treat severe Alzheimer’s. Behavioral and cognitive training can help as well. Research is being undertaken in clinical trials to include; immunization therapy, drug therapies, treatments used for cardiovascular disease and diabetes (National Institute on Aging, 2016).This patient must undergo further testing and examination with possible referral to a specialist to determine whether or not she has underlying pathology is in indeed related to dementia. Her metabolic function or side effects from medications and other considerations will be dealt with through blood testing. A simple mini mental exam can help determine if this is cognitive impairment. Confirmation of dementia would be accomplished by a collaborative process and multidisciplinary approach. References Alzheimer's Association. (2016). Dementia – Signs, Symptoms, Causes, Tests, Treatment, Care. Retrieved from http://www.alz.org/what-is-dementia.asp American Society of Health System Pharmacists, Inc. Dynamed . (2016 Feb 24). Atorvastatin. Ipswich, MA: EBSCO. Retrieved June 13, 2016, from http://www.dynamed.com American Society of Health System Pharmacists, Inc. Dynamed . (2016 Feb 24). Hydrochlorothiazide. Ipswich, MA: EBSCO. Retrieved June 13, 2016, from http://www.dynamed.com American Society of Health System Pharmacists, Inc. Dynamed . (2016 Feb 24). Lisinopril. Ipswich, MA: EBSCO. Retrieved June 13, 2016, from http://www.dynamed.com Boss, B. J. (2014). Alterations of Cognitive Systems, Cerebral Hemodynamics, and Motor Function. In McCance, K. L., Huether, S. E., Brashers, V. L. (Eds.), Pathophysiology: The biologic basis for disease in adults and children (7th ed., p. 550). St. Louis, MO: Mosby. Moyer, V. A. (2014). Screening for cognitive impairment in older adults: U.S. Preventive Services Task Force recommendation statement. Annals Of Internal Medicine, 160(11), 791-797.National Institute on Aging. (2016). About Alzheimer's Disease: Treatment. Retrieved June 13, 2016, from https://www.nia.nih.gov/alzheimers/topics/treatment#drugs 6/15/2016 7:22:23 PM Rechel DelAntar reply to Lorna Durfee RE: Discussion Part Two Hello Lorna, Great post. Medications are an important part to consider in cause of diseases. Different people react to medication differently and age plays a part on its effects. The cause of Alzheimer's is not yet well defined but is constantly being researched upon. One of the studies on Alzheimers was done by John Hopkins and published in 2013 in the journal Neurology, suggested that High blood pressure is one the of the causes of Alzheimer's Disease. That’s the intriguing finding from a Johns Hopkins analysis of previously gathered data, which found that people who took commonly prescribed blood pressure medications were half as likely to develop Alzheimer’s as those who didn’t. High blood pressure can damage small blood vessels in the brain, affecting parts of the brain responsible for thinking and memory. Researchers found that the use of potassium-sparing diuretics reduced the risk of Alzheimer’s nearly 75 percent, while people who took any type of antihypertensive medication lowered their risk by about a third (John Hopkins Medicine, 2013). This interesting because in this case, the patient is taking 2 anti-hypertensive meds, Lipitor and hydrochlorthiazide and should be a low risk to develop Alzheimer’s. However, it is an unknow if she has had a history of high blood pressure in the past and for how long. The patient may still has uncontrolled hypertension at this time despite medications at this time. Or is one of her medications causing her to have Azlheimer’s as you have pointed. It is a very interesting subject with different possibilities as to causation. At this point efforts are into treatment until there is a definitive answer to the cause of Alzheimer’s. Reference: John Hopkins Medicine. (2013). Blood Pressure and Alzheimer’s Risk: What’s the Connection. Retrieved from http://www.hopkinsmedicine.org/health/ healthy_aging/healthy_body/blood-pressure-and-alzheimers-risk-whats-the- connection. Rechel DelAntar Differential Diagnosis 6/14/2016 9:16:46 PM Hello professor and Class, Differential Diagnosis This is a case of a 77 year old that has been observed by the daughter to be increasingly withdrawn. Patient is only taking hypertensive meds, hydrochlorthiazide, lisinopril and atorvastatin. The daughter expresses a steep decline and verbalizes thatwhile doing grocery shopping, the patient became confused and angry with store employees who were trying to assist her. A possible differential diagnosis for this patient would be: Dementia of Alzheimer’s Type = Dementia is a general term for a decline in mental ability severe enough to interfere with daily life. Dementia is not a disease but a group of symptoms and can be caused by a variety of conditions, the most common of which is Alzheimer's disease. Alzheimer’s disease is the leading cause of dementia and one of the most common causes of severe cognitive dysfunction in older adults. Nonhereditary, or sporadic or late onset type is the most prevalent form (70%) (McCance, K.L., et. al., 2013). The most common early symptom is short-term memory loss. As a person's condition declines, they often withdraw from family and society. As the disease advances, symptoms can include problems with language, disorientation, mood swings, loss of motivation, not managing self care, and behavioral issues. The cause of Alzheimer's disease is not well understood. About 70% of the risk is believed to be genetic. Other risk factors include a history of head injuries, depression, or hypertension since the disease process is associated with plaques and neurofibrillary tangles (National Institute on Aging, 2011). Gathering accurate historical data as well as testing is important in order to be able to provide an accurate diagnosis. As primary care giver, is important to perform early cognitive screening among our elderly. Cognitive impairment in older adults has a variety of causes, including medication side effects, metabolic and/or endocrine imbalance, delirium due to illness, depression, and dementia, with Alzheimer’s dementia being most common. Some causes, like medication side effects and depression, can be reversed with treatment. Others, such as Alzheimer’s disease, cannot be reversed, but symptoms can be treated for a period of time and families can be prepared for predictable changes. Questions to ask the patient: 1. What is her current and past medical history? 2. What medications is she taking? 3. What is family’s medical history including dementia? 4. Ask her about her dietary intake? Ask about current or history of alcohol intake or abuse as well as substance abuse. 5. Ask her about her current mental and emotional state? Does she feel depressed, confused, agitated, angry and why? 6. A mini-cog test can also be performed to assess patient’s cognitive status. Complex questions to assess functional status are best done alone with the patient so family or companions cannot prompt the patient (National Institute on Aging, 2016). Questions for the family? 1. What behavior changes have you noticed and when did it start? 2. Allow family to voice concerns and give specific examples. 3. Confirm with family medications patient is supposed to be taking. 4. Ask about medical family history including dementia.5. Ask if the patient has had a history of alcohol or substance abuse past and present. The Alzheimer’s organization has developed and Alzheimer’s Identification tool, which is a questionnaire designed specifically for family members, which is used in conjunction with the patient’s mini-cog test and assessment can determine dementia among the elderly (Alzheimer’s Association, 2016). Treatment to Alzheimer’s involves different modalities. Trigger identification and behavior modification decreases anxiety, agitation and depression. Events of changes trigger behavioral symptoms. Change can be stressful for anyone and can be especially difficult for a person with Alzheimer's disease. It can increase the fear and fatigue of trying to make sense out of an increasingly confusing world. Identifying triggers can help in modifying the situation or environment as well as develop approaches to a situation before symptoms occur. Coping modalities by care givers such as monitoring comfort, avoiding confrontational behavior, redirecting attention, providing a quiet and clam environment, allow adequate rest, acknowledge request, explore other alternatives and not taking the behavior personally are helpful in caring for these patients. If non-drug approaches fail, medications may be appropriate for the patient. Medications used for this disease are Antidepressants (for mood), Anxiolytics (for anxiety/restlessness), Antipsychotic medications (for hallucinations) (Alzheimer’s Association, 2016). Reference: Alzheimer’s Association. (2016). Treatment for Behavior. Retrieved from http://www.alz.org/alzheimers_disease_treatments_for_behavior.asp Alzheimer’s Association. (2016). What is Dementia. Retrieved from http://www.alz.org/what-is-dementia.asp. National Institute on Aging. (2013). About Alzheimer’s Disease: Symptoms. Retrieved from https://www.nia.nih.gov/alzheimers/topics/symptoms. National Institute on Aging. (2016). Assessing Cognitive Impairment in Older Patients: A Quick Guide for Primary Care Physicians. Retrieved from https://www.nia.nih.gov/alzheimers/publication/assessing- cognitive-impairment-older-patients#instruments. McCance, K.L., Huether, S.E., Brashers, V.L. and Rote, N.S. (2013). Pathophysiology: The biologic basis for disease in adults and children (7 ed.). St. Louis,MO: th Mosby. Jennifer Roth reply to Rechel DelAntar RE: Differential Diagnosis 6/17/2016 7:38:03 AM Hi Rechel, I agree with you in that Alzheimer's disease/Dementia is the primary diagnosis. However, a UTI could also potentially be an option depending on the patient's history, medications, and symptoms. UTI's in the elderly are quite common and may be symptomatic or asymptomatic. A decline in mental or functional status may be seen in the elderly client with a UTI (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). Toxicity from infection can cause an altered mental status (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). Deterioration of mental status in a population with a high degree of cognitive impairment makes judging this indication of a UTI difficult (Hsaio, Yang, Hsaio, Hung,& Wang, 2015). Even so, research has shown that an altered mental state was the second most common indicator of bacteremia in the elderly (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). A decline in general status has been described as an indication and sometimes the only indication of a UTI in the elderly (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). This symptom may signal the subtle physical, mental, or functional changes that are present but difficult to describe in many elderly (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). Reference Hsaio, C.Y., Yang, H.Y., Hsaio, M.C., Hung, P.H., & Wang, M.C. (2015). Risk Factors for Development of Acute Kidney Injury in Patients with Urinary Tract Infection: e0133835. PLoS One, 10(7). doi: 10.1371/journal.pone.0133835 Lanre Abawonse Discussion Part Two 6/15/2016 12:10:13 AM What is your differential diagnosis based on the information you now have? Alzheimer Disease Alzheimer’s disease (AD) is a degenerative disorder of the brain that is manifested by dementia and progressive physiological impairment. It is the most common cause of dementia in the elderly but is not a normal part of aging. Age and family history are the biggest risk factors however, this patient has other risks factors such as being female, estrogen deficit after menopause, having hypertension and hyperlipidemia (McCance, Huether, Brashers, & Rote, 2013). Dementia Dementia is not a specific disease but rather a syndrome associated with pathological processes in which the generic term is characterized by cognitive and behavioral disorder. The behavior seen is progressive deterioration and continuing decline of memory and other cognitive changes. A sudden change is behavior may be an indication that it is not dementia, as dementia progresses slowly (Somes, Donatelli, & Barrett, 2010). Personality and behavior changes accompany the cognitive deterioration. Judgement, abstract thinking and complex task performance are all affected. Many demented patients have agnosia or lack of insight into their cognitive deficiencies. Drug induced psychosisDrugs such atorvastatin have been labeled to have unwanted effect in some patients. In some of my clinical experience, a patient was admitted to the hospital where I work for violent and aggressive behavior. According to family members, this patient exhibited symptoms of aggressiveness after taking atorvastatin. Some findings have claimed that one in four Americans could experience aggressive behavior after taking atorvastatin. Is it possible to for us to ever know if this is the case? Gauthier and Massicotte (2015) stated that drug induced psychosis is characterized by hallucinations, delusions, memory loss, and confusion. There is an ongoing investigation about the incidence of psychosis induced by atorvastatin. What other questions would you like to ask her now? (Questions can be asked of patient first, and then of reliable historian separately.) One of the basic ways of finding out the true illness of a patient is the ability to question the patient, with the hope that a correct picture will be accounted for during assessment history. In many cases, the family members are the most useful resources in getting the information. In light of this, Thornbory (2013) suggested to establish what investigations and treatment were given and what the person had been told by their primary physician or specialist. It would be vital to ask the patient and the family member who take care of the patient daily what prior event leads to this outburst. Has there been any stress (loss, financial, or family stressor), any recent sickness, has she had medication changes, are there any prescription medicine she is taken, if so how and when? Does she live alone or does she have someone to take care of her? Does she uses any recreational drugs (weed, cocaine, meth, etc)? Has she had and previous changes in mental status? How would you treat this patient and discuss why you give each medication or therapy you give. Since Alzheimer’s disease (AD) is a severe chronic neurodegenerative disease characterized by progressive cognitive impairment, functional decline and neuropsychiatric symptoms, one of the recommended treatments is the use of cholinesterase. Spalletta et. al., (2014) stated that cholinesterase inhibitors (ChEIs) are the most effective drugs available at present for treatment of mild to moderate AD, can stabilize cognitive symptoms for a one to three year period, but they are not able to modify the progression of the disease. There is also preliminary evidence that they may improve some neuropsychiatric symptoms. Unfortunately, the therapeutic response to ChEIs is less satisfying in the long-term period and some patients adhere to prescribed treatment for only a short time. Using Aricept 5mg a day can help in modifying the disease. This can be increased to 10mg a day after one month.Reference Gauthier, J. M., & Massicotte, A. (2015). Statins and their effect on cognition: Let’s clear up the confusion. Canadian Pharmacists Journal (Sage Publications Inc.), 148(3), 150. doi:10.1177/1715163515578692 Grimes, J. A. (2016). Alzheimer disease. In F. J. Domino (Ed.), The 5-minute clinical consult 2016 (24th ed., pp. 36-37). Philadelphia: Wolters Kluwer Health/ Lippincott Williams & Wilkins. Hort, J., O’Brien, J. T., Gainotti, G., Pirttila, T., Popescu, B. O., Rektorova, I.,& ... Scheltens, P. (2010). EFNS guidelines for the diagnosis and management of Alzheimer’s disease. European Journal of Neurology, 17(10), 1236-1248. doi:10.1111/j.1468-1331.2010.03040. McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2013). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Mosby. Somes, J., Donatelli, N. S., & Barrett, J. (2010). Sudden confusion and agitation: causes to investigate! Delirium, dementia, depression. Journal of Emergency Nursing: JEN: Official Publication Of The Emergency Department Nurses Association, 36(5), 486-488. doi:10.1016/j.jen.2010.06.010 Spalletta, G., Caltagirone, C., Padovani, A., Sorbi, S., Attar, M., Colombo, D., & Cravello, L. (2014). Cognitive and Affective Changes in Mild to Moderate Alzheimer’s Disease Patients Undergoing Switch of Cholinesterase Inhibitors: A 6-Month Observational Study. Plos ONE, 9(2), 1-9. doi:10.1371/journal.pone.0089216 Thornbory, G. (2013). Taking a history and making a functional assessment. Occupational Health, 65(3), 27-30. Sarah Boulware Part Two 6/15/2016 12:47:50 PM Dr. Brown and Class, 1. Drug Induced intoxication related to Atorvastatin Atorvastatin is a medication that lowers cholesterol levels by lowering low-density lipoprotein (LDL) levels and raising high-density lipoprotein (HDL) levels. It is a statin that works by slowing the production of cholesterol in the body to decrease the amount of cholesterol that may build up on the walls of the arteries and block bloodflow to the heart, brain, and other parts of the body. Side effects include forgetfulness or memory loss, confusion, lack of energy, extreme tiredness, weakness, and loss of appetite. The patient seems to be experiencing some of these side effects (U.S. National Library of Medicine, 2016). 2. Dementia related to Alzheimer’s Dementia is a disorder of cognition that interferes with daily functioning and results in loss of independence. The majorities of dementias are of a gradual onset, are progressive in course, and occur in people with previously normal cognition. Dementia is a culmination of dysfunction in the cerebral hemispheres. Diseases that cause dementia do so by affecting particular parts of the cerebra cortex, subcortical muscle, or the underlying white matter pathways that link different cortical regions. Neuropsychiatric symptoms are common. They include apathy, loss of initiative, depression, anxiety, and irritability. Anterograde amnesia is typically the first symptom present. The patient has experienced a gradual progression of her symptoms. (Knopman, 2012). 3. Depression Depression and anxiety are the most common psychiatric diseases among the elderly and often remain undiagnosed or untreated. Symptoms of depression include feelings of sadness, or feeling low, loss of interest and reduction of participation in daily life, negative talk, poor concentration, sleep disturbance, general appearance of looking sad or unkempt (Hardy, 2011). Questions I would first ask the patient and her daughter about her medications. When is the last time she took Atorvastatin? Has she missed any doses and tried to double up on doses? Has she had any alcohol with the medication? I would ask her these questions because alcohol can increase the risk of severe side effects or she may have been taking extra doses without realizing it due to her confusion. I full mental status exam is necessary as well. If her symptoms don’t appear to be from her medications I would suspect dementia as my primary diagnosis (U.S. National Library of Medicine, 2016). Treatment Alzheimer’s disease is the most common form of dementia and is a degenerative, incurable and terminal illness. Patients exhibit progressive cognitive failure and a decline in reasoning. There is no drug that can cure Alzheimer’s. Treatment to delay symptoms works best if initiated in the early stages. The choice of drug is determined by the stage of the disease. Cholinesterase inhibitors, like donepezil hydrochloride, rivastigmine, and galantamine, inhibit the enzyme acetylcholinesterase from breaking down the neurotransmitter acetycholine, which is essential for communication (Shan, 2013). References Hardy, S. (2011). Depression in the elderly: ways to offer support. Practice Nursing, 22(10), 520-525. Knopman, D. (2012). Alzheimer’s disease and other dementias. Goldman’s Cecil Medicine, 2, 2274-2283. Shan, Y. (2013). Treatment of Alzheimer’s disease. Primary Health Care, 23(6), 32-38. U.S. National Library of Medicine. (2016). Atorvastatin. Retrieved from https://www.nlm.nih.gov/medlineplus/druginfo/meds/a600045.html Instructor Brown reply to Sarah Boulware RE: Part Two 6/17/2016 8:45:45 AM I see how the medication Atorvastatin works. How would this cause the intoxication? How would it cause the S/E of memory loss, confusion?Sarah Boulware reply to Instructor Brown RE: Part Two 6/19/2016 3:17:04 PM Dr. Brown, Ford (2013) found that in general statins are well tolerated. Side effects include altered liver function, gastrointestinal effects such as flatulence, abdominal pain, diarrhea, nausea, and vomiting, and muscle aches. Muscle damage can progress to rhabdomyolosis. Less well known side effects include sleep disturbances, memory loss, and sexual dysfunction. The cause of these side effects is unclear. It is important to take into account patient reports of side affects and acknowledge that concordance with therapy may be influenced by individuals’ perceptions of side effects. Hepatotoxicity has been associated with atorvastatin. The cause is unknown but the drug is mostly metabolized in the liver and excreted in the bile. The Food and Drug Administration examined the complaints of memory loss, forgetfulness, and confusion for patients taking Atorvastatin. The cause for this side effect is still undetermined. References Ford, H. (2013). Use of statins to reduce the risk of cardiovascular disease in adults. Nursing Standard, 27(39), 48-56. Thank you, Sarah Boulware Alice Jeffries reply to Sarah Boulware RE: Part Two Sarah, I work in intensive cardiac rehabilitation and I see more an more physicians choosing not to prescribe statins to patients. My husband also had elevated total cholesterol, LDL, and triglycerides and his physician encouraged him to change his diet (he already works out almost every day and competes on weekends). I can see in progress notes that the doctors have counseled patients multiple times about lifestyle management changes, however that patients, like my husband, do not know how to make the changes. Eventually, many doctors seem to turn to medications if the patient continues to show worsening lab results. I love my job and watching people learn the tools to decrease cholesterol, weight, and improve lab results across the board. As a result of being my spouse, my husbands labs have also improved :) Ali Liberty Neoh Discussion Part Two 6/16/2016 3:17:51 PM Dr. Brown and Class, What is your differential diagnosis based on the information you now have? 6/20/2016 10:20:13 PMDementia is a syndrome characterized by cognitive or memory impairments and is associated with significant disability and impaired quality of life among older adults. The cognitive impairment characterizing dementia may include memory loss, difficulty in understanding or using words, inability to carry out motor activities despite adequate motor function, and failure to identify or recognize objects. People with dementia commonly experience impairments in occupational and social functioning and may present behavioral disturbances. (Tan et al, 2014). Infection The diagnosis of infection, such as urinary tract infection, in an older patient is often complicated by the lack of typical symptoms and a clear history but can cause mental confusion. Up to one-third of elderly patients do not present pyrexia in response to infection. The presence of cognitive impairment and communication difficulties can make it difficult to obtain an accurate history (Beveridge et al, 2011). Toxicity from her medications According to Xiao and his colleagues (2012), 23 % of patients admitted to emergency room with altered mental status (AMS) were due to medication toxicity. Electrolytes Imbalance is another cause of mental confusion in elderly. Calcium, in particular, is the second most frequent imbalanced electrolyte seen in patients. Calcium plays a role in cellular damage and cell death and intracellular enzymatic pathway. Researchers in this article mentioned that 51 % of patients had hypocalcemia and the other 4 % had hypercalcemia. Confusion was the most common physical findings during examinations, and this supposed to be a result of hypocalcemia in patients (Balci et al, 2013). What other questions would you like to ask her now? (Questions can be asked of patient first, and then of reliable historian separately.) When did she start having the symptoms (weeks, months)? Define the cognitive complaint and what are the functional impairments? Review her list of medications including OTC, herbal, etc., lab works. Conduct a thorough physical and neurological examination. A complete medical history, physical examination, and medication review are important components of the initial assessment of individuals presenting the memory and cognitive impairments characterizing dementia (Tan et al, 2014). How would you treat this patient and discuss why you give each medication or therapy you give. According to Gitlin and colleagues (2012) Nonpharmacologic treatments may be more beneficial to patients with dementia. This may include a general approach (caregiver education and training in problem solving, communication and task simplification skills, patient exercise, and/or activity programs), or a targeted approach in which precipitating conditions of a specific behavior are identified and modified (Gitlin et al, 2012). At best, current available pharmacologic treatments used to treat behaviors have modest efficacy and with associated risks and side effects. In addition, pharmacological regimen does not address behaviors most distressing for families. In sum, nonpharmacologic options are recommended as first-line treatments or if necessary, in parallel with pharmacologic treatment options.Substantial evidence shows that nonpharmacologic approaches can yield high levels of patient and caregiver satisfaction, quality of life improvements, and reductions in behavioral symptoms. Although access to nonpharmacologic approaches is currently limited, they should be part of standard dementia care (Gitlin, et al, 2012). With this treatment plan, families or caregivers must be willing to participate because their involvement in the process is necessary. References Balcı, A. K., Koksal, O., Kose, A., Armagan, E., Ozdemir, F., Inal, T., & Oner, N. (2013). General characteristics of patients with electrolyte imbalance admitted to emergency department. World Journal of Emergency Medicine, 4(2), 113–116. http://doi.org/10.5847/wjem.j.issn.1920-8642.2013.02.005 Beveridge, L. A., Davey, P. G., Phillips, G., & McMurdo, M. (2011). Optimal management of urinary tract infections in older people. Clinical Interventions in Aging, 6,173–180. http://doi.org/10.2147/CIA.S13423 Gitlin, L. N., Kales, H. C., & Lyketsos, C. G. (2012). Managing behavioral symptoms in dementia using nonpharmacologic approaches: An overview. Journal of Medical Association, 308(19). doi: 10.1001/jama.2012.36918 Tan, Z. S., Jennings, L., & Reuben, D. (2014). Coordinated care management for dementia in a large, academic health system. National Institute of Health. Health Affairs 33(4). doi: 10.1377/hlthaff.2013.1294. Xiao, H., Wang, Y., Xu, T., Zhu, H., Guo, S., Wang, Z., & Yu, X. (2012). Evaluation and treatment of altered mental status patients in the emergency department: Life in the fast lane. World Journal of Emergency Medicine, 3(4), 270–277. http://doi.org/10.5847/wjem.j.issn.1920-8642.2012.04.006 Instructor Brown reply to Liberty Neoh RE: Discussion Part Two 6/17/2016 8:46:53 AM What part of the infection process would cause confusion? What is the patho process? 6/17/2016 7:39:13 PM Liberty Neoh reply to Instructor Brown RE: Discussion Part Two Dr. Brown, According to Ali and colleauges (2011) infections may affect the production of cytokines, which are hormones that act on cells. These cytokines can trigger cerebral inflammation that can result in mental confusion. Cytokines have been shown to interrupt the transmission between neurons by affecting chemicals such as acetylcholine, dopamine, and norepinephrine. Thepresence of inflammation along with maturing brains of elderly patients might explain why these individuals are at an increased risk of acute cognitive dysfunction. Reference Ali, S., Patel, M., Jabeen, S., Bailey, R. K., Patel, T., Shahid, M., … Arain, A. (2011). Insight into delirium. Innovations in Clinical Neuroscience, 8(10), 25–34. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3225129/ 6/19/2016 5:25:20 PM Brooke Lobianco reply to Liberty Neoh RE: Discussion Part Two Liberty, Great post and thank you for your input! Infection with associated delirium is definitely an important differential to discuss. Infection can present a multitude of ways and as you mentioned, confusion is one of them, particularly in the elderly. Delirium is triggered when a susceptible individual is exposed to often multiple precipitating factors including infection, medications, pain and dehydration (Kukreja, Günther & Popp, 2015) The pathophysiological changes associated with delirium may add to the pre-existing cerebral disease and accelerate the progression of neurodegenerative process. Several pathophysiologic pathways including inflammation, cerebral hypoprofusion, oxidative stress, mitochondrial dysfunction, hypothalamic- pituitary- adrenal axis hyperrresponsiveness, and others may contribute to its long-term sequelae. While the precise mechanisms remain still incompletely understood, there is evidence that a disturbed interaction between various neurotransmitters including acetylcholine dopamine, noradrenaline, glutamate and gamma-amino hydroxybutyric acid (GABA) underlies the symptoms of delirium (Kukreja et al., 2015). Treatment of delirium should focus on identifying and managing the causative medical conditions, providing supportive care, and preventing and treating complications. Kukreja, D., Günther, U., & Popp, J. (2015). Delirium in the elderly: current problems with increasing geriatric age. Indian Journal Of Medical Research, 142(6), 655-662. doi:10.4103/0971-5916.174546 Michelle Demey Discussion Part Two 6/16/2016 4:45:59 PM The patient is a 77-year-old woman who has been more socially withdrawn lately and told her daughter she had not been feeling well. Her daughter has noticed a stepwise decline. While shopping for groceries with her daughter she became separated from daughter in the aisles. She became confused and angry when store employees and others tried to assist her. Her current medications are Hydrochlorothiazide, Lisinopril and Atorvastatin. Two differential diagnosis are: Vascular dementia and Alzheimer disease.Hallmark of vascular cognitive impairment is stepwise cognitive decline. Vascular dementia (VaD) is considered by some to be the second most common dementing illness after Alzheimer’s disease (AD). VaD comprises a group of mixed dementing disorders due to cerebrovascular insufficiency. Consequently, these disorders, may be a result of brain damage from multiple strokes, or infarcts, caused by small clots from heart or neck arteries that clog a branch of a blood vessel in the brain (Geschwind & Belkoura, 2016). Symptoms of VaD depend greatly on where strokes occur in the brain because specific areas of the brain control certain functions. Frequently, one of the initial strokes gives rise to a neurologic event or deficit that prompts the person or family to seek medical attention. It is at this point when a focused examination may reveal a degree of memory and cognitive impairment that had previously gone unnoticed The presentation of symptoms may be: memory impairment, language disturbance, difficulty walking, incontinence, emotionally labile, depression, impairment in motor skills, sensory disorders, and more abrupt loss of intellectual skills (Geschwind & Belkoura, 2016). A person with VaD may often experience more abrupt loss of intellectual skills as compared to a gradual loss in Alzheimer’s disease. The course of VaD often progresses in “steps”, with the person’s abilities remaining steady for a period of time and then declining rapidly (Geschwind & Belkoura, 2016). The reason for this “step-wise” course is the underlying cause of the vascular dementia. Alzheimer disease (AD) is the leading cause of dementia and one of the most common causes of severe cognitive dysfunction in older adults. The exact cause of AD is unknown and there is no clear understanding of this complex disease process. Early-onset familial Alzheimer disease (FAD) is autosomal dominant and has been linked to three gene defects: amyloid precursor, protein gene chromosome 21, presenilin on chromosome 14, and on chromosome 1. Late-onset AD may be associated with chromosome 19. Sporadic AD is the most common and does not have a specific genetic association. The greatest risk factors are age and family history. Other risk factors include: diabetes, midlife hypertension, hyperlipidemia, midlife obesity, smoking, depression, cognitive inactivity, female gender, physical inactivity, head trauma, and neuroinflammation (McCance & Huether, 2014). With most dementing illnesses, a definite diagnosis is possible only on autopsy with examination of brain tissue. However, a probable diagnosis is determined by: dementia, impairment of memory and 2 or more cognitive domains, cerebrovascular accidents, evidence of relevant cerebrovascular disease by brain scan imaging (CT or MRI), and probable association results when there is a temporal relationship between cognitive deficits and cerebrovascular lesions, abrupt or stepwise deterioration (Geschwind & Belkoura, 2016). VaD is neither reversible nor curable, but treatment of underlying conditions, such as high blood pressure, diabetes mellitus, may prevent further progression of the disorder (Geschwind & Belkoura, 2016). In this scenario continued treatment with blood pressure and cholesterol lowering medication would be recommended to reduce the risk of future cerebrovascular accidents and progression of VaD. Treatment of associated symptoms such as depression would also be recommended.Both patient and family should be involved with the treatment plan to assure safety and well-being of the affected patient. Questions should elicit information pertaining to recent behavioral changes, emotional patterns, and cognitive function. The patient told her daughter “I haven’t been feeling well” I would ask the her to tell me more about this. The clinical history should include cognitive testing, course of illness, laboratory test, and brain imaging (McCance & Huether, 2014). References Geschwind, M., & Belkoura, C. (2016). Non-alzheimer's and atypical dementia. West Sussex, UK: Wiley & Sons. McCance, K., & Huether, S. (2014). Pathophysiology: The biological basis for disease in Instructor Brown reply to Michelle Demey RE: Discussion Part Two adults and children vol. 1 (7th ed.). St. Louis, MO: Elsevier Mosby. 6/17/2016 8:48:08 AM You noted that a s/s may be incontinence. How is this possible with Vascular dementia? Michelle Demey reply to Instructor Brown RE: Discussion Part Two 6/18/2016 9:20:22 AM Cerebrovascular dementia is a matter of both large and small strokes along with accounts of lacunar syndromes. Multiple small infarcts in association with hypertension are the commonest pathological changes linked to VaD (Kalaria, 2016). The subcortical ischaemic form (SIVD) frequently causes cognitive impairment and dementia in the elderly, SIVD results from small-vessel disease, which produces either arteriolar occlusion and lacunes or widespread incomplete infarction of white matter due to critical stenosis of medullary arterioles and hypoperfusion. Signs include urinary symptoms probably as a result from ischemic interruption of parallel circuits from the prefrontal cortex to the basil ganglia and corresponding thalamocortical connections (Roman et al., 2016). References Kalaria, R. (2016, March 23). Neuropathological diagnosis of vascular cognitive impairment vascular dementia with implications for alzheimer's disease. Acta Neuropathol, 659-685. doi:10.1007/s00401-016-1571-z Roman, C., Erkinjuntti, T., Walin, A., Pantoni, L., & Chui, H. (2016). Subcortical ischaemic vascular dementia. The lancet neurology, 1(7), 426-436. doi:10.1016/S1474*4422(02)00190-4Jonathan Bidey Discussion Part Two 6/16/2016 5:14:02 PM Dr. Brown and Class, Considering the patient’s age and symptoms, her confusion could be from several causes. A differential diagnosis could include Alzheimer’s disease, age related dementia, or mental illness. However, considering her age and use of atorvastatin, my primary diagnosis would be an adverse reaction to atorvastatin. Adverse Reaction to Atorvastatin: Atorvastatin is a lipophilic statin drug used to treat dyslipidemia (Jacobson, 2014). Atorvastatin has been linked to contributing to confusion and irritability. As atorvastatin is lipophilic, it is able to cross the blood brain barrier, resulting in an inability to process information and reduced ability to recall (Jacobson, 2014). Of course, additional information would be required to make this diagnosis. Specifically, a mini-mental state examination or a Montreal cognitive assessment would be performed. These tests serve as excellent tools towards assessing recall, orientation, language, and attention (Jacobson, 2014). By assessing these aspects, the clinician is able to better judge if the patient is experiencing confusion. After this has been confirmed, recommendations include stopping the use of atorvastatin. Once this has occurred, the clinician can perform a second assessment to see if the patient’s cognitive function has returned. If so, pravastatin can then be ordered. Pravastatin is hydrophilic, and cannot pass the blood brain barrier (Jacobson, 2014). This makes atorvastatin a more desirable option for patients who have experienced a change in mental status while being treated with atorvastatin. -Jonathan Reference: Jacobson, T. A. (2014). NLA task force on statin safety- 2014 update. Journal of Clinical Lipidology, 8, 51-54. http://dx.doi.org/10.1016/j.jacl.2014.03.003 6/17/2016 7:27:39 AM Jonathan Bidey reply to Jonathan Bidey RE: Discussion Part Two Correction, final sentance should read as: This makes pravastatin a more desirable option for patients who have experienced a change in mental status while being treated with atorvastatin. Matthew Dove Week 7, Case Study 2 1) Dementia/ Major Neurocognitive Disorder 6/16/2016 6:12:15 PMIn 2013, the definition of dementia changed with the revision of the Diagnostic and Statistical Manual V (DSM-V). As a result, even the nomenclature changed for dementia states to be broadly classified as Major Neurocognitive Disorder (MND). Across the cognitive domains of a) Learning and Memory, b) Language, c) Executive function, d) Complex attention, e) Perceptual-motor function, and f) social cognition, a patient struggling with MND experiences gradual disturbances (vs. acute disturbances as seen with delirium) in these domains that interfere with independence and activities of daily life (American Psychiatric Association, 2013). The provided case study fits within the MND framework due to the social isolation (assuming she was typically socially engaged), confusion regarding her spatial ability and organization, labile behavior through outbursts, and stepwise decline are all characteristics of difficulties that patients with dementia encounter (Tsoi, Chan, Hirai, 2015) This is a particularly pertinent piece of information because a somatic ailment potentially would have more profound & acute findings (e.g. symptoms of a stroke of myocardial infarction). The instance of the daughter having to explain these disruptions, Coupled with the mood elements, demonstrates how dementia is classically an insidious, progressive onset of gradual neurodegeneration that is based on history and serial mental status examinations (American Psychiatric Association, 2013). Additionally, if the patient is experiencing MND, then potentially she is non-adherent with her medications and the complaint of “not feeling well” is the result of high blood pressure or cholesterol issues not being effectively managed. I would begin with a line of questioning that subscribed to understanding if this was indeed a MND and then rule out other diagnoses. To start, a Mini-mental status exam (MMSE) would be used to obtain baseline information and then attempt to obtain collateral information from family about functioning prior to symptoms of if another MMSE exists for comparison is available. The MMSE consists of the following orientation questions: 1) What is date (year, season, date, day, month), 2) Where are we (state, county, town, hospital, floor), 3) Name three objects (to test memory later on), 4) Serial 7’s or to spell WORLD backwards, 5) Ask again for the three objects, 6) Show and ask the patient to name a pencil and wrist watch, 7) Repeat the phrase, “No ifs, ands, or buts” 8) Follow a three stage command, 9) On a blank piece of paper write, ‘close your eyes’ and ask the patient to read and do what it says, 10) Give the patient a blank piece of paper and ask the patient to write a sentence containing a noun and verb and be sensible, and 11) Ask the patient to copy a design with angles present and intersecting. The maximum score of the MMSE is 30, with a score less than 24 points suggestive of dementia from the authors of the test (Folstein, Flostein, McHugh, 1975). I also would use the Mini-Cog test which consists of a clock drawing test and uncued recall of three unrelated words. With shorter administration time than the MMSE, the Mini-Cog has about the same sensitivity (76% vs. 79%) and specificity (89% vs. 88%) of the MMSE (Borson, Scanlan, Chen, Ganguli, 2003) for predictive value for dementia. Editorially, I would also ask patient about anti-cholinergic use over the lifespan as this has been correlated with dementia onset. Treatment would incorporate patient’s supportive network for education and tools to aid in re-orienting and guiding the patient. This treatment would holistically talk about the next steps in the process and discuss options for when the disease progresses (e.g. Assisted Living Community, Family support groups, potential for Hospice care). Medications to begin would include continuing the Thiazide and Anti-Hypertensive as well as medications such as Aricept or Namenda FDA approved in the treatment of MND. Acting as a reversible acetylcholinesterase inhibitor, medications are thought to slow mild to moderate MND, but in this patient it is essential to understand if the patient has heart disease as Donepezil should be used with caution in these cardiac populations (Noetzli , Eap 2013).It should be noted the terms MND and dementia noted above reference globally Alzheimer’s disease (compromising 70% of MND cases) and various dementia subtypes without referencing total spectrum of the disorder. Fully appreciating the spectrum of MND disorders is as follows: 1) Alzheimer's Disease, 2) Mild Cognitive Impairment (MCI) 3) Vascular Dementia, 4)Mixed Dementia, 5) Dementia with Lewy Bodies, 6)Parkinson's Disease, 7)Frontotemporal Dementia 8)Creutzfeldt-Jakob Disease, 9)Normal Pressure Hydrocephalus, 10) Huntington's Disease, 11) Wernicke-Korsakoff Syndrome (Alzheimer’s Association, 2016). 2) Cerebrovascular event Thiazide/Diuretic combination indicates hypertension and the statin medication further implicates the propensity for heart disease in the patient. Failure to lower blood pressure and cholesterol levels could lead heart attacks and stroke. A stroke will having a seemingly insidious, acute onset and our text purports that in altered consciousness occurs in 50% of individuals experiencing hemorrhagic strokes (Boss, Huether, 2013). It is difficult to comprehensively account for all symptoms based on the multitude of Cerebrovascular disorders, so testing is imperative to understand the full extent of insult to the patient through neuroimaging procedures like the CT, MRI, or Magnetic Resonance Angiography (MRA), or transcranial Doppler. If indeed, the patient has experienced a Cerebrovascular event, treatment is specific (e.g. tissue—type plasminogen activator [tPA] with 3 and up to 4.5 hours of onset in cerebrovascular events like ischemic stroke) to the offending disorder (Boss, Huether, 2013). The patient is this case study more than likely has already experienced the cerebrovascular event and treatment would consequently be supportive. 3) Late-life unipolar Depression (LLD) The neurobiological implications of major Depression Disorder after age 60 is theorized to resemble symptoms of dementia and very similar presentation to our case study. Espinoza and Kaufman (2014)propose the following theoretical basis, neuroimaging findings, and cognitive deficits and impairments for the frameworks of this concept (if unable to view in context, this image is additionally saved a .png file extension to this discussion thread): [Show More]

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