Alzheimer's - Nursing Case Study
Pathophysiology
• Primary mechanism: Alzheimer's involves the buildup of toxic proteins in the brain, specifically Beta-amyloid plaques and Tau tangles. Beta-amyloid plaques are sticky clumps of protein fragments that block neuron communication. Tau tangles are twisted strands of another protein that damage nutrient transport within neurons, causing their death.
• Secondary mechanism: As Alzheimer's progresses, brain inflammation increases. Microglia, the brain's immune cells, try to clean up the plaques and tangles but can become overactive, leading to chronic inflammation, which further damages neurons.
• Key complication: The combination of protein buildup and inflammation leads to the loss of neuron connections, cell death, and total brain atrophy. This process begins in the hippocampus, affecting memory first, before spreading to other brain areas, impacting further cognitive and motor functions.
Patient Profile
Demographics:
82 years old, female, retired school teacher
History:
• Key past medical history: Hypertension, osteoporosis
• Current medications: Amlodipine for hypertension, Calcium and Vitamin D supplements for osteoporosis
• Allergies: Penicillin
Current Presentation:
• Chief complaint: Occasional memory loss
• Key symptoms: Forgetting names or appointments, misplacing items, difficulty finding the right words, slight confusion with time or place
• Vital signs: Blood pressure 130/80, heart rate 70 bpm, respiratory rate 15 breaths per minute, body temperature 98.6 F, Oxygen saturation 98%
Section 1
Change in Patient Status:
Over the next few weeks, the patient's memory problems seem to become more noticeable. During visits, her daughter reports that she has found her mother wandering around the neighborhood, appearing disoriented and confused. She also mentions instances where her mother repeatedly asks the same questions and forgets conversations that had just occurred.
At home, the patient struggles with daily tasks such as cooking, cleaning, and taking her medications. She also seems more forgetful about her doctor's appointments and needs to be reminded by her daughter. Despite these challenges, the patient's vital signs remain relatively stable: Blood pressure 132/85, heart rate 68 bpm, respiratory rate 16 breaths per minute, body temperature 98.7 F, Oxygen saturation 98%.
This progression of symptoms suggests the need for further evaluation and possibly a change in the patient's care plan. It would be beneficial for the patient to have a cognitive assessment to evaluate the severity of her memory loss and to possibly confirm a diagnosis of Alzheimer's disease. This assessment would also help in guiding the next steps in her treatment plan, which could include environmental modifications, medication adjustments, and potentially the introduction of cognitive-enhancing medications.
Section 2
Initial Assessment Findings:
Upon conducting a cognitive assessment, the results indicate a moderate level of cognitive impairment. The Mini-Mental State Examination (MMSE) score was 18 out of 30, suggesting early-stage Alzheimer's disease. The patient displayed difficulty with tasks involving recall, attention, and language. She was unable to recall three objects after a short delay and struggled with basic arithmetic tasks. She also had difficulty following instructions to copy a complex figure.
In addition to the cognitive assessment, the nurse also conducted a comprehensive physical examination. The patient's motor skills were intact, her speech was coherent, and her cranial nerves were functioning normally. There were no signs of stroke or other neurological disorders. However, the nurse observed that the patient seemed disoriented to time and place, often asking what day it was or where she was. She also had difficulty recalling details of her medical history, which was corroborated by her daughter.
This assessment confirmed the need for a revision in the patient's care plan. The nurse would need to consult with the healthcare team to discuss the options for managing the patient's condition. This may include introducing cognitive-enhancing medications, implementing strategies to improve memory and cognitive function, and arranging for supervised care to ensure the patient's safety.
Section 3
Following the initial assessment, the healthcare team decided to introduce cognitive-enhancing medications, specifically donepezil, to manage the patient's early-stage Alzheimer's disease. The patient was started on a low dose of 5mg daily at bedtime, with the plan to increase the dosage gradually over time as tolerated. The team also initiated memory-enhancing activities such as puzzles and brain games to help improve cognitive function.
After two weeks, the patient was seen for a follow-up assessment. Her daughter reported that she seems more oriented to time and place, and episodes of confusion have decreased. The patient's MMSE score improved to 20 out of 30, indicating an improvement in cognitive function. However, the daughter also noted that the patient has been experiencing some gastrointestinal disturbances, including occasional nausea and loose stools, which are known side effects of donepezil. The nurse informed the healthcare team about these side effects, and they decided to keep the patient on the current dose of donepezil while monitoring her closely for any further complications. The nurse also educated the patient and her daughter about the importance of taking the medication with food to minimize gastrointestinal side effects.
Section 4
Three weeks later, the patient returned for another follow-up. The patient's daughter reported that the gastrointestinal side effects have persisted despite taking the medication with food. She also mentioned that her mother experienced mild dizziness on a few occasions. The nurse performed a comprehensive assessment of the patient. Vital signs were within normal limits: blood pressure was 120/80 mmHg, pulse was 75 beats per minute, and respiratory rate was 16 breaths per minute. Her weight remained stable.
The healthcare team decided to perform a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) to rule out any underlying conditions that might be contributing to these symptoms. The results were generally within normal range except for a slightly elevated liver enzyme, alanine aminotransferase (ALT), which was 45 U/L (normal range 7-35 U/L). The team decided to monitor the liver function closely while continuing the current dose of donepezil, considering its benefits on the patient's cognitive function. The nurse reiterated to the patient and her daughter the importance of reporting any new or worsening symptoms promptly.
Section 5
Two weeks later, the patient's daughter called the healthcare team, reporting that her mother had been experiencing increased fatigue and loss of appetite. She also noticed a slight yellowing of her mother's eyes and skin. The nurse recognized these symptoms as possible signs of liver dysfunction, possibly related to the slightly elevated ALT level noted in the previous lab results. The healthcare team decided to bring the patient in for an urgent assessment.
Upon examination, the patient's vital signs were blood pressure 118/78 mmHg, pulse 72 beats per minute, and respiratory rate 14 breaths per minute. Her weight was slightly decreased, indicating a loss of 2 lbs since her last visit. The patient's eyes and skin did indeed exhibit a mild jaundice. The healthcare team ordered another CMP, this time with a focus on liver function tests including aspartate aminotransferase (AST), alkaline phosphatase (ALP), and bilirubin levels in addition to a repeat ALT. The results showed an ALT of 60 U/L, an AST of 45 U/L (normal range 10-35 U/L), and a total bilirubin of 2.2 mg/dL (normal range 0.1-1.2 mg/dL), suggesting a potential drug-induced liver injury. The healthcare team discussed the need for possible adjustments in the patient's medication regimen, considering these new findings. The nurse emphasized to the daughter the importance of close monitoring of her mother's symptoms and maintaining good hydration and nutrition.