NU 664B Week 8 Discussion 1: Memory Loss

Differential Diagnosis:

1. Dementia – This is the most likely diagnosis for this patient. A patient with dementia may present with worsening memory and cognition. They may exhibit problems with language and alterations in personality. The dementia may be related to Alzheimer’s disease or multi-infarct dementia, or vascular dementia which may result after CVA (Dunphy et al.,2019). When formulating a differential, it is always important to foremost consider the most common diagnoses. This patient is 70 years old, and it is important to note that almost 15% of people older than 70 years old have dementia (Dunphy et al.,2019). In order to make the diagnosis the patient must have a disturbance in activities of daily living related to functional decline (Dunphy et al.,2019). This patient does display these criteria as her daughter reports she has started to need help with grocery shopping, she is forgetting to take her medications, she needs assistance with managing finances, and there are concerns related to her cooking due to an episode of leaving the stove on. The concussions that she experienced increase her risk for developing Alzheimer’s disease (June et al., 2020).  In order to diagnose dementia, other neurocognitive disorders need to be ruled out (Dunphy et al.,2019). In order to rule in the diagnosis, I would need to have the patient complete a MMSE or MoCA screening (Dunphy et al.,2019).
2. Depression with anxiety- Depression is an extremely common psychiatric disorder in the geriatric population with 11-35 % of older adults experiencing significant depressive symptoms. Deteriorating cognitive function is frequently seen in older adults experiencing depression (Muhammad & Meher,2021). This patient does exhibit some signs of depression such as fatigue and sleeping more during the daytime. She reports some loneliness since her husband passed away. In order to rule in or out this diagnosis I would want her to complete a PH9 questionnaire for further evaluation.
3. Metabolic disturbance- Metabolic problems can result in fluid-electrolyte, and acid-base imbalances which can cause confusion. To rule in this diagnosis the provider would look for signs of dehydration on exam such as dry skin, poor skin turgor, or low-grade fever. Labs would need to be ordered for further evaluation such as a comprehensive metabolic panel, urinalysis, and thyroid function. There may also be other signs such as dizziness, altered level of consciousness, and hypotension (Dunphy et al.,2019). In this particular patient, I would be more concerned about dementia than a metabolic disturbance causing her symptoms because they have been gradual in onset and the patient is still alert. However, she is on chlorthalidone which can cause electrolyte disturbances so that is a risk factor for her. I would order labs for further evaluation and if they were normal that would rule out a metabolic disturbance and help to rule in dementia by exclusion.
4. Infectious process- Confusion can be caused by infectious processes due to tissue and organ impairment from release of toxins or ischemia which produces cell injury and death. Septicemia or bacteremia can present as delirium (Dunphy et al.,2019). I would suspect this to be less likely in this patient due to the fact that she is alert and the symptoms have been gradual in onset. However, I would still rule out infectious processes before confirming diagnosis of dementia. On physical exam I would be looking for signs of infection such as hypotension, tachypnea, tachycardia, abnormal lung sounds, or fever (Dunphy et al.,2019). I would order labs for further evaluation such as a CBC to determine if there is any leukocytosis and a urinalysis and culture to make sure there are no signs of infection.

Plan: Primary Differential Diagnosis: Dementia Pharmacology If the patients MMSE or MoCa were positive and other causes of memory loss were ruled out as above, then I would discuss with the patient and daughter risks vs benefits of starting Aricept 5 mg orally daily. I would have her continue her home medications as below based on results of labs. Atorvastatin 40 mg one tab by mouth once a day Metformin 500 mg one tab by mouth once a day Aspirin 81 mg one tab by mouth once a day Amlodipine 5 mg one tab by mouth once a day Chlorthalidone 25 mg one tab by mouth once a day I would recommend using Tylenol extra strength 2 caps every 8 hours as needed in place of ibuprofen due to her history of hypertension. Non-Pharmacology I would encourage the patient to continue exercising as being physically active is important. I would encourage the patient to be socially active as well by recommending joining local senior center to be involved with activities with others and keep the mind stimulated. I would recommend getting involved in Tai-Chi which could help with balance and help to prevent falls. I would refer the patient for home health services including nursing which could provide a home safety assessment and help with medication management and organizations such as the VNA may be able to offer home health aid services to assist with ADLs and IADLs. Elder Services would be another option.  Physical therapy could help prevent falls related to her osteoarthritis. Diagnostics: CBC with diff, CMP, A1C, lipids, TSH reflex FT4, B12, RPR, urinalysis reflex to culture. Consults/Referrals: Referral to neuropsychiatrist to further evaluate for dementia vs. depression. Referral to neurology Referral for home health services/ elder services. Referral for safety driving assessment Would offer referral to therapist/ grief counselor. Patient education: 1. Continue physical exercise 2. Do mind exercises such as puzzles or games 3. Be socially active 4. Follow a health diet such as the DASH diet to keep blood pressure well controlled 5. Continue to avoid alcohol 6. Have annual eye exam to reduce the risk of falls 7. Avoid sleeping for long periods during the day to help promote restful sleep at night and reduce night time awakening 8. I would educate the patient and daughter on the importance of establishing advance directives at this time such as health care proxy and MOLST 9. Would discuss need for driving safety assessment 10. Would discuss long term health care planning discuss that dementia is progressive and need for home safety assessment at this time but need to consider future living arrangements if becomes no longer safe for patient to be alone 11. Would discuss that Aricept starting dose is 5 mg but if tolerating may consider increasing to 10 mg daily 12. Would discuss that most common side effects are nausea, vomiting, and diarrhea and they should call office with development of side effects. 13. I would instruct the daughter to monitor for effectiveness of the drug by assessing if there is any improvement in functioning at home. 14. Would discuss need to report any worsening of condition and would make sure daughter and patient know to report any sudden changes in cognition right away. (Arvanitakis et al., 2019). (Dunphy et al.,2019) Follow up: Would follow up in 1-2 weeks to discuss results of labs and see how patient is doing on new medication. Health Maintenance: Would discuss the importance of continuing to exercise and discuss following a health diet such as the DASH diet. Would make sure she is up to date on all vaccinations including covid-19, flu, pneumonia, shingles, and TDAP. (Dunphy et al.,2019). Social Determinants of Health: It is important to consider the social determinants of health as they relate to the aging process when caring for this patient. Pain, fatigue, and weakness can lead to decreased social engagement and result in isolation and loneliness ( Perez et al.,2022). It would be important to consider that if the patient loses her license related to her memory problems this could put her at increased risk of isolation due to lack of transportation. It would be important to connect this patient with elder services for resources.

References

Arvanitakis, Z., Shah, R. C., & Bennett, D. A. (2019). Diagnosis and management of dementia: review. JAMA, 322(16), 1589–1599. https://doi.org/10.1001/jama.2019.4782 Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary Care (5th ed.). F. A. Davis Company. June, D., Williams, O. A., Huang, C. W., An, Y., Landman, B. A., Davatzikos, C., Bilgel, M., Resnick, S. M., & Beason-Held, L. L. (2020). Lasting consequences of concussion on the aging brain: Findings from the Baltimore Longitudinal Study of Aging. NeuroImage, 221, 117182. https://doi.org/10.1016/j.neuroimage.2020.117182 Muhammad, T., & Meher, T. (2021). Association of late-life depression with cognitive