NR 507 PATHOPHYSIOLOGY WEEK TD2 Behavioral, Neurologic, and Digestive Disorders Discussion Part Two (NR507)

Exam (elaborations) NR 507 PATHOPHYSIOLOGY WEEK TD2 Behavioral, Neurologic, and Digestive Disorders Discussion Part Two (NR507) Discussion Part Two Disorders - Loading... Loading... Discussion Discussion Part Two (graded) Responses Lorna Durfee 6/13/2016 2:50:10 PM Discussion Part Two aYnodu rt opladt iheenrt disa uag 7h7t-eyre sahre- ohladd w noomt abne ewnh foe ehlainsg b weeenll .m Hoerre dsoacuigahlltye rw hiathsd nroatwicne dla ate ly ssteeppawraistee dd efrcolimne d. aWughhiltee rs hino ptphien agi sfolers g. rSohcee brieecsa wmieth c ohnerfu dsaedu gahntder a, nsghrey b wechaemn es tore eHmydplrooycehelso raontdh ioatzhideres, Ltriiseidn otop rails,s aisntd h Aert.o Hrvears medications are • What is your differential diagnosis based on the information you now have? • What other questions would you like to ask her now? (Questions can be asked of patient first, and then of reliable historian separately.) • How would you treat this patient and discuss why you give each medication or therapy you give. Doctor Brown: fTihnidsi npga thieenr tw aapyp.e aSrhs eto a lbseo edxehmibointisntgra steigs nsso mofe l oasgsi toatfi omne. mFororym a hnedr hsayvminpgto dmifsf iacnudlt y sbieg nthse, sshtaer ti so ef xAhlizbhiteiinmg efro’rsg oert fduelnmeesns with confusion and irritability; this could When evaluating this patient consideration of current medications are be drug interactions and toxic effects of certain medications. 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Walseo c noeueldd tuos ed oth ae pFhoylsstiecianl mexianmi-.m Tenhteanl qwuee swtioounlnda nireee.d tWo ed oc oau mldi nais-km heenrt aifl she aknndo whes rw nhaemree .s Whee i sc.o uWlde hcaovuel dh earls sop aesllk a i f“ WsheO kRnLoDw”s bthaec kdwataer,d t.h eW tiem me,u tsht ea sPsreesssi dheenrt , vmiseintt caol ustladt ufisl la unsd irne voine wde htaeirl sm oefd wichaatito tnhse.y T hhaev fea ombisleyr mveedm abnedr sg itvhea ta a dcceotamilpedan hyi stthoirsy . cWoned citoiounld u rnudne srloymineg f tuhritsh ecrh abnlogoed. tests to determine if there is any metabolic What is your differential diagnosis based on the information you now have? Io ft hdienmk ethnatita t.h Tish pe aAtileznhte sihmoewr’ss sAigsnsso coifa tmioinld e cxopglaniintisv teh iamt dpeamirmenetniat aisn dn opto as ssipbelec iofincs et ddiescelainsee ibnu tm aenm oovreyr aolrl ttherinmk itnhga.t oDuetlmineenst iaa rlainmgiets o tfh esy pmerpstoonm’ss athbailti tayp ptoe apre wrfiotrhm a activities of daily living. Alzheimer’s accounts for 60 to 80 percent dementia, however, vascular dementia is the second most common toyfp teh we ocarssee s of (Alzheimer's Association, 2016). pTrhoebrlee marse. o Tthheer Acolznhdeitiimonesr’ ssu Achss aosc itahtyioroni dli sotrs vsiotmame ionf d tehfei ccioenndciietiso tnhsa ut ncdaner c wauhsaet is cmounssti dbeer eimd pdaeimreedn. t iTa.h eI fc poareti emnetsn thaal vfeu ndcetmioennst iaar ea;t mleeamst otwryo, ccoomrem muennictaalt ifounn,c atinodn s lpaenrgceupatgieo,n a. bTilhietyre t oc afno cbues parnodb lpeamys a wtteitnht isohno, rrte-taesromn imnge manodr yju, dpgayminengt b ainllds ,v pirseupaal ring amneda ltsh ea nsdy mtrpavtoemlins gc ainnt ost aurntk snloowwlny aanndd rtehceong gneizt ewdo arrseea (sA. lDzheemimenetri'ass A asreso pcrioagtiroens,s ive, 2m0e1d6ic).a Ttiohner sei daree e offthecetrs p, reoxbcleesmsisv eth uast ec aouf sael cmohemolo, rthyy irsosiude sa,n sdu vchit aams;i dne dperfeiscsiieonnc,i es (Alzheimer's Association, 2016). DMiisleda csoe.g nTithievree i ims pmaiilrdm menetm iso ray s lyomssp tfoomr r eficresnt ts eaennd inne twh ei npfroorgmreastisoionn i no fe aArllzyh setiamgee r’s pAllaznhneiinmge arn’sd D diisseoariseen. t aInti oonth teor lwocoartdios,n t.h eTrhee irse sihso arlts-ote prmos smibelme odreyp rloessssi, odni fafincdu lmtyi lwd ith (aMnxciCetayn. c Te,h Heruee itsh earl,s o& m Birldas ihnesrtsr,u 2m0e1n4t,a lp a. c5t5iv0i) of daily living tHhoerwa pwyo yuoldu ygoivue t?r eat this patient and discuss why you give each medication or pEasttiaebnltiss hsihnogu tlhde b cea euvsael ufoart etdh iws ditehm laebnotirnagto pryro acnedss n meuaryo pbsey vcehroyl ocgoimc ptelisctiantegd a. nHdo bwraeivne r, idmepargeisnsgio. n T thhee uussee ooff naenutirdoeleppretiscs amnetsd iccaanti boen sa pcopuroldp rbiaet ec o(nMsicdCearendc.e , I fH thueerthe eirs, & Brashers, 2014, p. 546). pMeooypeler a( r2e0 a1 4k)n oanwdn T rihsek Ufancittoerd fSotra cteosg Pnirteivveen itmatpivaeir mTaesnkt. F Torhceer es taartee oththaet ro rldisekr faagcetdo rs shuecahd atrsa duimabae, tdeesp, rteosbsaicocno, aunsde ,p hhyypseicrcahl ofrleasiltteyr.o lAemlsioa,, tahned l ahcykp eorft ean psrioopne. r Asu hpipsotorrt y of tsayssktes mth. aTt hreeq sucirreee antitnegn ttieosnts, msuegmgoesryte,d l aanrge ufaogr ec oangdn ivtiivseu aiml-sppaaitrimale anbt,i laintide st.h aTt hine cmluodset s tuessetd, 7m-metihnoudte i ss cthreee Mn, ianni-dM qeunetsatli oSntnataei rEe xoanm ciongantiiotinv.e Tdhecelrien ies ianl sthoe t heeld celrolcyk. dTrhaew ing irnechoibmitmoresn adnedd mtreeamtmanetnint ew. i tThh pehya arlmsoa croelcoogmicm aegnedn tcso ignnciltuivdee st raacinetiynlgc,h loifleinsteysltee rase 2m0o1d4i,f ipc.a 7ti9o2n)s. a nd behavioral, exercise, education and multidisciplinary care (Moyer, aTphper oNvaetdio bnyal t Ihnes Utitnuittee do nS tAatgeisn gF o(2o0d1 a6n)d t eDllr uugs Athdamt tihneirsetr aarteio mn etod itcraetaito tnhse t hsyamt aprteo ms of Amlozdheeriamtee rA’sl zDheisiemaesre’.s .T Aheryic aerpet; aDnodn Mepeemzialn (tAinreic (eNpat)m, reinvdaast)i gcamni nbee fuosre md tiold t rtoea t severe uAnlzdheertiamkeern’ si.n Bcleinhiacvailo trraila lasn tdo ciongclnuidtiev;e i mtraminuinnigz actaionn h tehlper aasp yw, edlrl.u gR tehseeraarpcihe si,s being t2r0e1at6m).ents used for cardiovascular disease and diabetes (National Institute on Aging, This patient must undergo further testing and examination with possible specialist to determine whether or not she has underlying pathology is in rienfdeerreadl to a roetlhaetre dc oton sdideemraetnitoina.s wHielrl bmee dtaebaoltl iwc iftuhn tchtriooung ohr bsildoeo de ftfeesctitns gf.r o Am smimedpilcea mtioinnis manedn tal ewxoaumld c baen ahceclpo mdeptleisrhmeidn eb yif at hciosl ilsa bcoorgantiivtiev ep riomcpeassir manedn mt. uClotindfiisrcmipaltiinoanr yo fa dpepmroeancthia. References Alzheimer's Association. (2016). Dementia – Signs, Symptoms, Causes, Tests, Treatment, Care. Retrieved from American Society of Health System Pharmacists, Inc. Dynamed . (2016 Feb 24). Atorvastatin. Ipswich, MA: EBSCO. Retrieved June 13, 2016, from American Society of Health System Pharmacists, Inc. Dynamed . (2016 Feb 24). Hydrochlorothiazide. Ipswich, MA: EBSCO. Retrieved June 13, 2016, from American Society of Health System Pharmacists, Inc. Dynamed . (2016 Feb 24). Lisinopril. Ipswich, MA: EBSCO. Retrieved June 13, 2016, from Boss, B. J. (2014). Alterations of Cognitive Systems, Cerebral Hemodynamics, and Motor Function. In McCance, K. L., Huether, S. E., Brashers, V. L. (Eds.), Pathophysiology: The biologic basis for disease in adults and children (7th ed., p. 550). St. Louis, MO: Mosby. Moyer, V. A. (2014). Screening for cognitive impairment in older adults: U.S. Preventive Services Task Force recommendation statement. Annals Of Internal Medicine, 160(11), 791-797. National Institute on Aging. (2016). About Alzheimer's Disease: Treatment. Retrieved June 13, 2016, from Rechel DelAntar reply to Lorna Durfee 6/15/2016 7:22:23 PM RE: Discussion Part Two Hello Lorna, Great post. Medications are an important part to consider in cause of diseases. Different people react to medication differently and age plays a part on its effects. The cause of Alzheimer's is not yet well defined but is constantly being researched upon. One of the studies on Alzheimers was done by John Hopkins and published in 2013 in the journal Neurology, suggested that High blood pressure is one the of the causes of Alzheimer's Disease. That’s the intriguing finding from a Johns Hopkins analysis of previously gathered data, which found that people who took commonly prescribed blood pressure medications were half as likely to develop Alzheimer’s as those who didn’t. High blood pressure can damage small blood vessels in the brain, affecting parts of the brain responsible for thinking and memory. Researchers found that the use of potassium-sparing diuretics reduced the risk of Alzheimer’s nearly 75 percent, while people who took any type of antihypertensive medication lowered their risk by about a third (John Hopkins Medicine, 2013). This interesting because in this case, the patient is taking 2 anti-hypertensive meds, Lipitor and hydrochlorthiazide and should be a low risk to develop Alzheimer’s. However, it is an unknow if she has had a history of high blood pressure in the past and for how long. The patient may still has uncontrolled hypertension at this time despite medications at this time. Or is one of her medications causing her to have Azlheimer’s as you have pointed. It is a very interesting subject with different possibilities as to causation. At this point efforts are into treatment until there is a definitive answer to the cause of Alzheimer’s. Reference: John Hopkins Medicine. (2013). Blood Pressure and Alzheimer’s Risk: What’s the Connection. Retrieved from healthy_aging/healthy_body/blood-pressure-and-alzheimers-risk-whats-theconnection. Rechel DelAntar 6/14/2016 9:16:46 PM Differential Diagnosis Hello professor and Class, Differential Diagnosis This is a case of a 77 year old that has been observed by the daughter to be increasingly withdrawn. Patient is only taking hypertensive meds, hydrochlorthiazide, lisinopril and atorvastatin. The daughter expresses a steep decline and verbalizes that while doing grocery shopping, the patient became confused and angry with store employees who were trying to assist her. A possible differential diagnosis for this patient would be: Dementia of Alzheimer’s Type = Dementia is a general term for a decline in mental ability severe enough to interfere with daily life. Dementia is not a disease but a group of symptoms and can be caused by a variety of conditions, the most common of which is Alzheimer's disease. Alzheimer’s disease is the leading cause of dementia and one of the most common causes of severe cognitive dysfunction in older adults. Nonhereditary, or sporadic or late onset type is the most prevalent form (70%) (McCance, K.L., et. al., 2013). The most common early symptom is short-term memory loss. As a person's condition declines, they often withdraw from family and society. As the disease advances, symptoms can include problems with language, disorientation, mood swings, loss of motivation, not managing self care, and behavioral issues. The cause of Alzheimer's disease is not well understood. About 70% of the risk is believed to be genetic. Other risk factors include a history of head injuries, depression, or hypertension since the disease process is associated with plaques and neurofibrillary tangles (National Institute on Aging, 2011). Gathering accurate historical data as well as testing is important in order to be able to provide an accurate diagnosis. As primary care giver, is important to perform early cognitive screening among our elderly. Cognitive impairment in older adults has a variety of causes, including medication side effects, metabolic and/or endocrine imbalance, delirium due to illness, depression, and dementia, with Alzheimer’s dementia being most common. Some causes, like medication side effects and depression, can be reversed with treatment. Others, such as Alzheimer’s disease, cannot be reversed, but symptoms can be treated for a period of time and families can be prepared for predictable changes. Questions to ask the patient: 1. What is her current and past medical history? 2. What medications is she taking? 3. What is family’s medical history including dementia? 4. Ask her about her dietary intake? Ask about current or history of alcohol intake or abuse as well as substance abuse. 5. Ask her about her current mental and emotional state? Does she feel depressed, confused, agitated, angry and why? 6. A mini-cog test can also be performed to assess patient’s cognitive status. Complex questions to assess functional status are best done alone with the patient so family or companions cannot prompt the patient (National Institute on Aging, 2016). Questions for the family? 1. What behavior changes have you noticed and when did it start? 2. Allow family to voice concerns and give specific examples. 3. Confirm with family medications patient is supposed to be taking. 4. Ask about medical family history including dementia. 5. Ask if the patient has had a history of alcohol or substance abuse past and present. The Alzheimer’s organization has developed and Alzheimer’s Identification tool, which is a questionnaire designed specifically for family members, which is used in conjunction with the patient’s mini-cog test and assessment can determine dementia among the elderly (Alzheimer’s Association, 2016). Treatment to Alzheimer’s involves different modalities. Trigger identification and behavior modification decreases anxiety, agitation and depression. Events of changes trigger behavioral symptoms. Change can be stressful for anyone and can be especially difficult for a person with Alzheimer's disease. It can increase the fear and fatigue of trying to make sense out of an increasingly confusing world. Identifying triggers can help in modifying the situation or environment as well as develop approaches to a situation before symptoms occur. Coping modalities by care givers such as monitoring comfort, avoiding confrontational behavior, redirecting attention, providing a quiet and clam environment, allow adequate rest, acknowledge request, explore other alternatives and not taking the behavior personally are helpful in caring for these patients. If non-drug approaches fail, medications may be appropriate for the patient. Medications used for this disease are Antidepressants (for mood), Anxiolytics (for anxiety/restlessness), Antipsychotic medications (for hallucinations) (Alzheimer’s Association, 2016). Reference: Alzheimer’s Association. (2016). Treatment for Behavior. Retrieved from Alzheimer’s Association. (2016). What is Dementia. Retrieved from National Institute on Aging. (2013). About Alzheimer’s Disease: Symptoms. Retrieved from National Institute on Aging. (2016). Assessing Cognitive Impairment in Older Patients: A Quick Guide for Primary Care Physicians. Retrieved from impairment-older-patients#instruments. McCance, K.L., Huether, S.E., Brashers, V.L. and Rote, N.S. (2013). Pathophysiology: The biologic basis for disease in adults and children (7 ed.). St. Louis,MO: Mosby. th Jennifer Roth reply to Rechel DelAntar 6/17/2016 7:38:03 AM RE: Differential Diagnosis Hi Rechel, I agree with you in that Alzheimer's disease/Dementia is the primary diagnosis. However, a UTI could also potentially be an option depending on the patient's history, medications, and symptoms. UTI's in the elderly are quite common and may be symptomatic or asymptomatic. A decline in mental or functional status may be seen in the elderly client with a UTI (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). Toxicity from infection can cause an altered mental status (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). Deterioration of mental status in a population with a high degree of cognitive impairment makes judging this indication of a UTI difficult (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). Even so, research has shown that an altered mental state was the second most common indicator of bacteremia in the elderly (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). A decline in general status has been described as an indication and sometimes the only indication of a UTI in the elderly (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). This symptom may signal the subtle physical, mental, or functional changes that are present but difficult to describe in many elderly (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). Reference Hsaio, C.Y., Yang, H.Y., Hsaio, M.C., Hung, P.H., & Wang, M.C. (2015). Risk Factors for Development of Acute Kidney Injury in Patients with Urinary Tract Infection: e. PLoS One, 10(7). doi: 10.1371/. 6/Lanre Abawonse 15/2016 12:10:13 AM Discussion Part Two hWahvaet? is your differential diagnosis based on the information you now Alzheimer Disease Alzheimer’s disease (AD) is a degenerative disorder of the brain that is manifested by dementia and progressive physiological impairment. It is the most common cause of dementia in the elderly but is not a normal part of aging. Age and family history are the biggest risk factors however, this patient has other risks factors such as being female, estrogen deficit after menopause, having hypertension and hyperlipidemia (McCance, Huether, Brashers, & Rote, 2013). Dementia Dementia is not a specific disease but rather a syndrome associated with pathological processes in which the generic term is characterized by cognitive and behavioral disorder. The behavior seen is progressive deterioration and continuing decline of memory and other cognitive changes. A sudden change is behavior may be an indication that it is not dementia, as dementia progresses slowly (Somes, Donatelli, & Barrett, 2010). Personality and behavior changes accompany the cognitive deterioration. Judgement, abstract thinking and complex task performance are all affected. Many demented patients have agnosia or lack of insight into their cognitive deficiencies. Drug induced psychosis Drugs such atorvastatin have been labeled to have unwanted effect in some patients. In some of my clinical experience, a patient was admitted to the hospital where I work for violent and aggressive behavior. According to family members, this patient exhibited