Alzheimer's - Nursing Case Study

Pathophysiology

• Primary mechanism: Brain cell death - Alzheimer's results in nerve cell death and tissue loss throughout the brain. Over time, the brain shrinks significantly, affecting nearly all its functions. This is caused by two types of abnormalities: plaques and tangles.

• Secondary mechanism: Plaques and Tangles - Plaques are clumps of protein called beta-amyloid that damage and destroy brain cells in several ways. Tangles are twisted fibers of another protein called tau that build up inside cells, leading to failure in nutrient transportation and eventual cell death.

• Key complication: Memory Loss - One of the main symptoms of Alzheimer's is memory loss, especially recalling recent events or new information. This is due to the damage in the hippocampus, the part of the brain essential for learning and memory. As Alzheimer's progresses, more parts of the brain are damaged, leading to severe cognitive decline.

Patient Profile

Demographics:

82, female, retired schoolteacher

History:

• Key past medical history - Hypertension, osteoporosis

• Current medications - Amlodipine for hypertension, alendronate for osteoporosis, donepezil for Alzheimer's

• Allergies - Penicillin

Current Presentation:

• Chief complaint - Family members noticed occasional forgetfulness and difficulty performing familiar tasks

• Key symptoms - Repeated questions, trouble handling money and paying bills, taking longer to complete normal daily tasks, forgetting familiar locations

• Vital signs - Blood Pressure: 130/80, Pulse: 75, Respiratory Rate: 16, Temperature: 98.6 F, Oxygen Saturation: 98%

Section 1

Initial Assessment Findings:

During the initial assessment, the patient was oriented to person and place but had difficulty with time; she was unable to recall the current date. Her speech was clear and coherent, but she struggled with some word-finding difficulties. Upon conducting the Mini-Mental State Examination (MMSE), she scored 22 out of 30, indicating mild cognitive impairment. Her cranial nerves were intact, and no motor or sensory deficits were noted. Pupils were equal, round, and reactive to light and accommodation.

Her Cardiovascular examination was unremarkable with a regular rhythm and no murmurs or extra heart sounds. Respiratory examination revealed clear lung fields bilaterally. Her blood glucose level was 105 mg/dl, within normal limits. Her calcium levels were slightly elevated at 10.2 mg/dl, indicating a need for further monitoring given her osteoporosis diagnosis. Her thyroid function tests were normal, eliminating hypothyroidism as a cause for her memory issues. The patient's blood pressure was well controlled with her current medication. The initial assessment findings will guide the nursing care plan, focusing on cognitive stimulation, safety, and promoting independence.

Section 2

Change in Patient Status:

During a follow-up assessment two weeks later, the patient presented with a slight decline in cognitive function. She was still oriented to person and place, but her difficulty with time had worsened. She was not aware of the day of the week and thought that it was still morning, despite it being afternoon. Her speech remained clear, but she displayed increased word-finding difficulties. On repeating the MMSE, she scored 20 out of 30, indicating a progression in her cognitive impairment.

Despite these cognitive changes, her physical health remained stable. Her blood pressure was still well-controlled with her current medication and her blood glucose levels remained within normal limits. Her calcium levels had slightly increased to 10.5 mg/dl, making it necessary to adjust her osteoporosis management plan. No new physical symptoms or complications were noted. This change in her cognitive status necessitates a revision of the nursing care plan, with an increased emphasis on cognitive stimulation and safety measures, while still promoting her independence.

Section 3

Change in Patient Status:

During the next follow-up visit, the patient's cognitive function appeared to have declined further. She was now having difficulty recognizing familiar objects and often misplaced household items. She also had trouble remembering the names of close family members. During a routine cognitive assessment using the MMSE, she scored 17 out of 30, indicating a further drop in her cognitive abilities. This decline, combined with her increased difficulty in performing activities of daily living, led to a diagnosis of moderate-stage Alzheimer's disease.

Her physical health, however, remained largely unchanged. Her blood pressure was 130/80 mmHg, and her blood glucose was 95 mg/dL, both within the normal range. Her calcium levels were now at 10.3 mg/dL after the adjustment of her osteoporosis medication. She did complain about occasional headaches, but a neurological examination didn't reveal any abnormalities. This further decline in her cognitive status calls for a revision in the nursing care plan, with an emphasis on maintaining her physical health, managing her confusion, and ensuring her safety at home. This would involve a team approach, including the nurse, the doctor, and family members.

Section 4

Change in Patient Status:

During a subsequent visit, it was noted that the patient's confusion and forgetfulness had increased. She would frequently lose track of time and had difficulty remembering recent events. Additionally, she was now unable to perform complex tasks, such as managing finances or planning meals. These symptoms indicated an advancement of her Alzheimer's disease.

However, her physical health markers remained stable. Her blood pressure was 130/70 mmHg, and her blood glucose level was 98 mg/dL, which are within the normal range. Her calcium level was 10.2 mg/dL, indicating the osteoporosis medication was adequately managing her bone health. The nurse also assessed her for signs of dehydration and malnutrition, given her increasing forgetfulness, but found no concerning signs. The increased cognitive impairment necessitates a re-evaluation of her care plan to ensure the patient's safety and well-being, and to facilitate optimal functioning despite her cognitive decline. This will involve an increased focus on providing a safe environment, simplifying tasks, and offering cognitive stimulation activities.

Section 5

Change in Patient Status:

During the subsequent visit, the nurse noticed a change in the patient's behavior. She seemed more agitated and frequently misplaced items, leading to increased frustration. The patient also demonstrated difficulty in finding the right words during conversations, often substitifying unrelated words, a condition known as aphasia. Moreover, her ability to concentrate and make decisions had visibly declined. She was frequently disoriented to time and place, and there was a noticeable increase in her passive behavior, indicating a progressive decline in her cognitive abilities.

The nurse decided to conduct a Mini-Mental State Examination (MMSE) to assess the patient's cognitive function. The MMSE score was 20 out of 30, which indicated mild cognitive impairment. This was a decrease from her previous score of 25, six months ago. Her blood pressure remained stable at 130/70 mmHg, her blood glucose was 98 mg/dL, and her calcium level was 10.2 mg/dL. However, the nurse observed that the patient had lost 5 pounds over the past month, which could be a sign of decreased appetite or difficulty in meal preparation due to her cognitive decline.

The new findings call for a reassessment of her care plan, focusing more on managing her cognitive symptoms, ensuring nutritional needs are met, and providing a structured and reassuring environment to deal with her increasing agitation.