alzheimer - Nursing Case Study

Pathophysiology

• Primary mechanism: Accumulation of Beta-amyloid plaques - Alzheimer's disease is predominantly caused by the abnormal build-up of beta-amyloid proteins in the brain. These proteins clump together, forming plaques that disrupt neuronal communication, leading to cell death and brain atrophy.

• Secondary mechanism: Neurofibrillary tangles - Another key factor is the formation of neurofibrillary tangles, composed of hyperphosphorylated tau protein. These tangles block the transport of essential nutrients and molecules within neurons, causing cell damage and loss of function.

• Key complication: Memory loss and cognitive decline - The destruction of neurons and their networks due to the above mechanisms result in memory loss, confusion, and other cognitive difficulties, which are the hallmark symptoms of Alzheimer's disease. The medial temporal lobe, which is crucial for memory, is typically affected first, followed by other areas responsible for language and reasoning.

Patient Profile

Demographics:

78, Female, Retired School Teacher

History:

• Key past medical history: Diagnosed with Alzheimer's disease 3 years ago, high blood pressure

• Current medications: Donepezil for Alzheimer's, Lisinopril for high blood pressure

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Difficulty remembering recent events, increased confusion, unsteady gait

• Key symptoms: Memory loss, confusion, difficulty with complex tasks, mood swings, trouble walking, frequent falls

• Vital signs: Blood Pressure 150/90 mmHg, Pulse 85 bpm, Temperature 98.6°F, Respiratory Rate 18 breaths per minute

Section 1

Change in Patient Status:

Over the past week, the patient's condition has noticeably deteriorated. Her confusion has worsened, making communication increasingly challenging. Family members report that she has started to wander at night and has difficulty recognizing familiar faces, including her own children. They also note that her mood swings have become more severe and unpredictable. Additionally, she has lost significant weight, as she often forgets to eat and drink. Her vital signs remain relatively stable with a blood pressure of 152/92 mmHg, pulse 86 bpm, temperature 98.7°F, and respiratory rate 16 breaths per minute.

New Complications:

Unfortunately, a new complication has arisen. The patient suffered a fall in her home and was found by her daughter with a swollen, painful right hip. She was immediately brought to the emergency department. An X-ray confirmed a fracture of the right hip. This new injury, combined with her worsening cognitive status, poses a significant challenge to her care. It is crucial to manage her pain effectively and plan for surgical intervention while considering the increased risk due to her advanced Alzheimer's disease and high blood pressure. The medical team needs to balance the urgency of the hip surgery with the potential risk of anesthesia and postoperative delirium in a patient with Alzheimer's disease.

Section 2

Change in Patient Status:

After two days of hospitalization, the patient's cognitive status continued to decline. She was found attempting to get out of bed, crying out in pain due to her fractured hip and unable to comprehend the need to stay bedridden. Her agitation increased and she frequently called out for family members, often not recognizing them when they were in the room. Despite the nursing staff's best efforts to reorient her, the patient was unable to retain new information. Her blood pressure spiked to 170/100 mmHg during these episodes of confusion and agitation, posing an increased risk of cardiovascular complications.

Response to Interventions:

The medical team initiated pain management using acetaminophen and opioids, closely monitoring her respiratory rate due to the risk of respiratory depression. Her pain seemed somewhat under control, but her confusion and agitation remained high. A low dose of an antipsychotic was initiated to manage her agitation. To address her nutritional needs, a dietitian was consulted and a plan was put in place to provide high protein, high calorie meals with assistance for feeding. Despite these interventions, her weight dropped another two pounds, suggesting the need for further intervention.

New Complications:

During a routine check, the nurse noticed that the patient's right hip and leg were significantly more swollen compared to earlier assessments, and the skin was warm to touch. Her temperature spiked to 100.4°F, suggestive of a possible infection. Blood samples were taken immediately for complete blood count and cultures, and a Doppler ultrasound was ordered to check for a possible deep vein thrombosis. The new complication could potentially delay the surgical intervention for her hip fracture and complicate her overall management.

Section 3

New Diagnostic Results:

Lab results revealed a leukocyte count of 15,000/mm3, indicating an active infection. The cultures were still pending. The Doppler ultrasound confirmed the presence of deep vein thrombosis in her right lower extremity. Her INR was 1.0, suggesting that her blood was not thin enough to prevent clots. Additionally, her albumin levels were low at 2.5 g/dL, indicating malnutrition and potentially contributing to her poor wound healing and infection risk.

Change in Patient Status:

Her agitation worsened in the evening, a phenomenon known as "sundowning" in Alzheimer's patients. In addition to her elevated blood pressure, her heart rate increased to 110 bpm, and her respiratory rate was 22 breaths per minute. The patient appeared more disoriented, repeatedly asking where she was and why she couldn't get up. Her pain seemed to be increasing despite the analgesics, with the patient rating it as 8 on a scale of 10. The increased swelling, warmth, and pain in her right hip and leg were concerning for worsening of her deep vein thrombosis and possible development of a septic joint.

Section 4

Response to Interventions:

Despite the administration of anticoagulation medication, her symptoms pertaining to deep vein thrombosis seemed to be worsening. This was a clear indication that the current treatment regimen was proving to be insufficient. The patient's pain was still not under control, even with the regular administration of analgesics. Additionally, measures to manage her agitation, such as reorienting her to time, place, and situation, and providing a calm and soothing environment, were only providing temporary relief, as her agitation would worsen again during the evening hours.

New Complications:

The patient's condition took a turn for the worse when she began to develop a fever with a temperature of 38.5 degrees Celsius. Her leukocyte count spiked to 18,000/mm3, indicating that the infection was worsening. Her worsening disorientation and agitation, combined with new onset fever and increased leukocyte count, raised concerns for the possibility of sepsis, a potentially life-threatening condition. The potential for a septic joint also loomed, as the right hip and leg continued to be swollen, warm, and painful. The possibility of delirium, a common complication in hospitalised elderly patients with dementia, also needed to be considered given her worsening disorientation and agitation.

Section 5

Change in Patient Status:

The patient's status deteriorated over the subsequent days. Her fever spiked to 39.3 degrees Celsius despite the administration of antipyretics. The patient's level of consciousness also began to fluctuate, with periods of severe agitation and confusion interchanging with moments of drowsiness and lethargy. Her respiratory rate increased to 24 breaths per minute, and her oxygen saturation dropped to 92% on room air. Clinically, her right lower leg appeared more edematous and erythematous, and the pain seemed to have escalated, as indicated by her grimacing and protective behavior of the affected limb.

New Diagnostic Results:

Blood cultures were obtained, and the results returned positive for Staphylococcus aureus, a common pathogen associated with sepsis. The patient's D-dimer levels also remained elevated at 0.9 mg/L (normal range: <0.5 mg/L), suggesting persistent thrombosis. A joint aspiration was conducted, which revealed purulent fluid, further raising suspicions for a septic joint. A computed tomography (CT) scan of her chest was ordered to rule out any pulmonary embolism, given her increased respiratory rate and decreased oxygen saturation. This cascade of worsening clinical features and supporting diagnostic findings pointed towards an escalating scenario of septicemia, possibly secondary to a septic joint and complicated by a persistent deep vein thrombosis. The unfolding clinical picture necessitated urgent reassessment of the patient's management plan.