Please enable JavaScript.

Coggle requires JavaScript to display documents.

Susanna and Carline - Part 1 - Coggle Diagram

- - - - Susanna attributes this to mobility. Thinks she is living well at home alone and maintaining healthy diet.
        
        Our Concerns: is this a rapid onset change in ADL/iADL? Depression? Mobility? Dementia/AMS? Dietary/malnourished contributing to unsteadiness?
        
        Carline found fridge almost empty, mother has not been eating due to losing her dentures. Susanna didn't go to grocery store after reassuring Carline that she would go that day. Susanna constantly rearranging belongings, looking for glasses/keys, misplacing items. Carline believes Susanna may be missing BP med doses (fewer refills). She also finds her sleeping in her chair in the middle of the day
        
        Differentials: AMS from medications (polypharmacy), delirium, dementia, dehydration, UTI from glucouria/Lasix
        
        Medications can impact older people differently (Fatigue, general mood). Don't know how frequently she is taking medications. Concern for caregiver strain - Driving over to mother's house much more frequently.
        
        Exam Findings: BP 146/82, HR 88, RR 18, 10 lbs loss from 1 yr ago. PMH compensated HFpEF, HTN, mild OA, PM. Social hx: 30+ yr smoking, quit age 50. Meds: Amlodipine 10mg daily, Lasix 20mg daily, Tylenol, NyQuil PM, Pepto PRN.
        
        10lbs wt loss very concerning
        
        Labs:
        
        Dr. Balgrist asks if Susanna will agree to being asked specific questions (MMSE) and she agrees (reluctantly)
        
        Susanna possibly in denial - fear of being placed in nursing home. Reluctance - could be anxiety/worry. She could refuse the test; however, concern would have been decisional capacity if she refused test.
        
        MMSE Results:
        
        Scoring: Total score 19/30. Concern for moderate dementia. Problem areas: 4/5 on orientation. Recall. Attention/calculation. 3-stage command
        
        What is the positive/negative predictive value of the MMSE?
        
        Agrees to discuss results with Carline. Weight loss = concerning. Plasma lipid profile not normal but not horrible. No new meds needed. Arrange for visiting nurse to help make a plan to cope with ADL and adherence to medications. "Meals on Wheels" -- delivery of healthy meals to seniors
        
        Susanna's memory is moderately impaired. Possible Alzheimer's disease. Carline is upset. How do you know her memory impairment is Alzheimer's and not something else? Is there a type of memory loss more common in people with high BP than in those who do not have high BP and high cholesterol? Is the doctor assuming it is AD based on their race? Medications interfering with memory? Is there a drug that slows memory loss in people with early onset AD? Would she be a good candidate for this medication Clinical trials for this medication did not include significant # of Black people. Latest literature?
        
        5 more items...
- - - - There also may be biases in the testing and neuropsychiatric evaluation of AD that disproportionally affect the prevalence of AD in African American patients.
  - - - AD: Generalized brain atrophy in medial temporal lobe and hippocampus
      - VD: Cerebrovascular lesions - white matter hyper-intensities and infarcts (subcortical regions)
    - - Vascular dementia: stepwise deterioration in cognitive function
      - Alzheimer’s Disease: gradual and progressive decline in cognitive function
    - - AD: amyloid PET scans can detect amyloid-beta plaques, Tau PET for visualization of neurofibrillary tangles
      - VD: patchy patterns of hypometabolism in subcortical regions
    - - AD: elevated total tau and phosphorylated tau, low levels of amyloid-beta 42
  - - - Conservator: court appointed or voluntary designated
      - Health care representative: can make real-time decisions with physicians
      - Living Will: documented wishes; guidance
  - - - Fun fact, memory care in 2023 in CT averaged over $6,000 per month, so if patients want to be in a facility specific for memory care, they often need to fund it themselves
        
        However, in Connecticut, Medicaid Part C has an application program for elders can cover some services for older adults with dementia, including care management, adult day healthcare, companion services