MODULE 23: CONCEPT OF COGNITION

Case Study: Parts 1, 2, and 3

Case Study, Part 1 (pp. 1715–1716)

Victor Wallace is a 74-year-old Caucasian male who was diagnosed with moderate Alzheimer disease 2 years ago. Mr. Wallace lives with his 50-year-old daughter, Anne Marie, who is his primary caretaker. His wife of 52 years died of pancreatic cancer 18 months ago.

Mr. Wallace presents at his gerontologist’s office at 9:30 on Thursday morning. Ms. Wallace requested the appointment because she is concerned about the changes she has seen in her father over the past month. As the nurse working with Mr. Wallace’s gerontologist, you conduct an initial assessment and interview with Mr. Wallace and Ms. Wallace. Ms. Wallace reports that Mr. Wallace has exhibited increased confusion and anxiety at home and at the adult day care center he attends each day while she is at work.

In the past, Mr. Wallace only had these problems in unfamiliar settings. He is also experiencing a decline in language, increasingly using the wrong words to describe common objects and relying on scanning speech to find words. However, Ms. Wallace’s main concern is her father’s refusal to carry out the basic activities of daily living (ADLs) he is still capable of performing. When you ask Mr. Wallace about the ADLs, he says, “There’s no point in trying because I won’t be able to do them much longer.” As you observe Mr. Wallace, you note that he seems agitated. He is sitting on the edge of his chair, tapping his foot and rapping his hands on his knees. When you ask him basic questions, he has a hard time coming up with answers. When he can’t find the words he wants, he just repeats the phrase “That’s how it is.”

Mr. Wallace’s vital signs and weight are normal, and his physical condition is good for a man his age. You administer the Cornell Scale for Depression in Dementia and his score is 17, indicating high probability of depression. The gerontologist maintains Mr. Wallace’s current dose of 28 mg of memantine (Namenda) per day to slow the progression of his Alzheimer symptoms. She then adds sertraline (Zoloft), an SSRI, to treat his depression symptoms. Mr. Wallace is to start out taking 50 mg of sertraline per day, gradually working up to 150 mg per day over a 6-week period.

Question 1

How do your observations of Mr. Wallace correlate with the changes Ms. Wallace reports?

Question 2

What aspects of Mr. Wallace’s presentation prompt you to test him for depression?

Question 3

Why might Mr. Wallace’s increased confusion in familiar settings be a concern for Ms. Wallace?

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Question 4

Why is it important to distinguish between Mr. Wallace’s refusal to perform ADLs and an inability to do so?

Question 5

Would speech therapy be an appropriate intervention for Mr. Wallace? Why or why not?

Question 6

Refer to the exemplar on Alzheimer disease in this module: How would a change in Mr. Wallace’s Alzheimer medication from an NMDA receptor antagonist like memantine to an acetylcholinesterase inhibitor like donepezil affect the doctor’s choice of SSRI for depression?

Case Study, Part 2 (p. 1723)

In the winter after his visit to the gerontologist, Mr. Wallace begins experiencing increased agitation and wandering in the afternoons and evenings. One afternoon at the adult day care center, Mr. Wallace slips out the door undetected. By the time the day care providers realize he’s gone, he has left the grounds and is wandering the neighborhood. The day care providers call Ms. Wallace and 911, and a search for Mr. Wallace commences. Ms. Wallace and two police officers find Mr. Wallace 2 miles from the day care center. He has no idea where he is or how he got there. He has taken a fall, and his face and hands are covered in scrapes.

The officers radio for an ambulance as Ms. Wallace attempts to talk to Mr. Wallace. He panics because he does not recognize his daughter, and he pushes her to the ground. He then throws punches at the officers when they prevent him from running away. The paramedics arrive and restrain Mr. Wallace. Once he is restrained, Ms. Wallace is able to calm him down. He is then transported to the emergency department, where you are the admitting nurse.

Mr. Wallace is calm upon his arrival at the hospital, and you are able to treat his injuries without incident. You attempt to speak with him, but he indicates he is tired and promptly falls asleep. You use this opportunity to interview Ms. Wallace. She states that aggression has become common during her father’s increasingly frequent periods of confusion. Sometimes he doesn’t recognize her; other times, he mistakes her for his sister. He is also increasingly unable to use basic objects—such as pencils, toothbrushes, and combs—and relies on Ms. Wallace for many basic ADLs. In addition, he occasionally experiences urinary and fecal incontinence. Ms. Wallace is shaken by the day’s events and the situation in general, and she begins to cry.

When Mr. Wallace’s gerontologist arrives in the ED, you inform her of these developments. She adds 20 mg of buspirone (BuSpar) three times daily (tid) to Mr. Wallace’s treatment regimen to lessen his agitation and aggression. The doctor also tells Ms. Wallace that Mr. Wallace is starting to transition from moderate to severe Alzheimer disease, and she recommends that Ms. Wallace begin looking for a nursing home that specializes in the care of individuals with this condition.

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Question 1

What are the priorities for Mr. Wallace’s care to decrease his risk of wandering and injury during his remaining time at home?

Question 2

What independent interventions can you perform to address the caregiver role strain felt by Ms. Wallace?

Question 3

What additional information or education do you anticipate Ms. Wallace will need in light of the doctor’s recommendation?

Question 4

Which of Mr. Wallace’s symptoms indicate he is transitioning from moderate to severe AD?

Question 5

What steps can Ms. Wallace take at home to lessen the incidence and severity of Mr. Wallace’s sundowning episodes?

Question 6

Why is it important for Ms. Wallace to find an institutional care situation for Mr. Wallace now rather than waiting until he reaches a more severe stage of AD?

Case Study, Part 3 (p. 1728)

After his wandering episode, Mr. Wallace’s condition rapidly declines. His communication skills are almost completely gone; he speaks infrequently and uses only two- or three-word sentences. He no longer recognizes Ms. Wallace, cannot perform ADLs, and is indifferent to food. His tendency toward wandering and aggression has disappeared. In fact, he rarely leaves his room. For his safety and to allow for provision of the care he needs, Mr. Wallace is admitted to an extended care facility that specializes in treating patients with Alzheimer disease.

You are the nurse assigned to care for Mr. Wallace. As part of his daily assessment, you obtain his vital signs, which include temperature 99.8°F oral; pulse 92 bpm; respirations 32/min; and blood pressure 108/74 mmHg. Auscultation of Mr. Wallace’s lungs reveals faint bibasilar crackles. On reviewing his chart, you note that he has experienced a 5% weight loss since the previous month. You notify the attending physician about Mr. Wallace’s vital signs, breath sounds, and weight loss. The physician orders a chest x-ray and complete blood count (CBC).

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Question 1

What is the significance of Mr. Wallace’s vital signs and breath sounds?

Question 2

What effect might Mr. Wallace’s weight loss have on his cognitive condition?

Question 3

What important pieces of information might be gleaned from tracking Mr. Wallace’s food intake and weight?

Question 4

What is the priority nursing diagnosis for Mr. Wallace at this time?

Question 5

What independent interventions can you perform to optimize Mr. Wallace’s respiratory status? What positive effects might these have on other aspects of his health?

Question 6

Refer to the exemplar on Alzheimer disease in this module: Would Mr. Wallace’s condition improve with the addition of a cholinesterase inhibitor to his treatment regimen? Why or why not?