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Case Study For Old Male With Memory Loss And Urinary Incontinence

Case Study For Old Male With Memory Loss And Urinary Incontinence

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One of the most common groups of conditions that usually affect the elderly (above 65 years of age) is that of neurocognitive (neurodegenerative) disorders (APA, 2022; Boland et al., 2021). The most common of these is Alzheimer’s disease or AD. It is characterized by disorientation, speech and language problems, altered cognition, memory loss, and inability to perform by oneself activities of daily living such as toileting, grooming, bathing, and feeding. This collection of symptoms is referred to as dementia (Kelley et al., 2018)Case Study For Old Male With Memory Loss And Urinary Incontinence. If not managed properly, AD progresses to stages that see the patient deteriorate and become incontinent for both urine and stool (Bartolone et al., 2021). Environmental variables, lifestyle choices, and heredity are among the elements that contribute to dementia and Alzheimer’s disease. This implies that the illness may be passed down from parents to children as well. These same hereditary components combine with appropriate environmental cues to cause the signs of Alzheimer’s disease, including the syndrome of dementia. The purpose of this paper is to examine the case of a 77-year-old male with amnesia and urinary incontinence in terms of subjective and objective information, treatment, and health education.

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Case Summary/ Synopsis

Patient H is a 77-year-old male who is not a new patient to the practice. He has a past medical history of hypertension; hyperlipidemia, knee osteoarthritis, coronary artery disease, and high fasting blood glucose (type 2 diabetes mellitus?). He is presented to the clinic by his daughter who reports a complaint of renewed “confusion and urinary incontinence.” On presentation his vital signs were BP 130/84; HR 60, RR 16; T 99.2 °F; BMI 38 kg/m2 (obesity). At evaluation the patient can recognize people round him and the place. He however cannot recall recent events or even tell the time.

The patient claims that he is feeding and taking fluids normally, but the daughter disagrees. Patient H also claims that his bowel movements have not changed; but admits he is afraid of falling asleep lest he wets his bed. It is reported by the daughter that he has recently shown polydipsia making him drink water a bit excessively of late. It is also reported that the polydipsia is accompanied by polyuria. Apart from the knee pain attributable to his arthritis, the patient reports no other pain. He used to frequent the local senior center but has not been there for a week now and has forgotten about it altogether. Case Study For Old Male With Memory Loss And Urinary Incontinence

Patient H is taking a few over-the-counter (OTC) medications and preparations; including Aleve, multivitamins, glucosamine-chondroitin tablets, and a topical application for the knee pain. His prescription medications at the time of being seen are:

  1. Lisinopril (Zestril) 20 mg PO daily.
  2. Hydrochlorothiazide (Aquazide) 12.5 mg PO daily.
  3. Metoprolol (Lopressor) 50 mg PO daily.
  4. Simvastatin (Zocor) 20 mg PO daily.

Additional Subjective Information Needed

There is quite a variety of additional subjective information that is to be gathered from patient H and this includes (Carlat, 2023):

Family History

The patient’s family history needs to be known. As has been stated in the introduction, a good number of mental illnesses including AD are hereditary. Getting to know the family history of mental illness and any other illnesses will help shed light on the patient’s own conditions. For instance, if the father or mother had AD, it would follow that he most likely inherited the condition from them genetically. Also, if a close relative had type II diabetes, the polydipsia, polyuria, and elevated fasting blood sugars would be explained by that history of diabetes in the family. A look at his current medications shows that he has not been started on any medication(s) for the elevated blood sugars. Case Study For Old Male With Memory Loss And Urinary Incontinence

Substance Use History

It is also important to know if the patient has a history of substance abuse. If they do, it may explain their redisposition to the development of mental illness. This could be the primary mental illness or even a comorbid mental illness. A prolonged history of substance use is often followed by mental illness.

Personal Psychiatric History

It has been stated that this is not a new patent at the practice. This means that he has a history of psychiatric illness and has been seen at the facility before. To understand his situation better, it is crucial that this past psychiatric history is known. Looking at the medications that he is currently on, there is none that is a psychotropic medication. This means that whatever psychiatric history that he has, he has not yet been started on the correct treatment for it.

Allergies

Knowing the presence or absence of allergies is crucial in safely treating patient H. some allergies may prove to be life-threatening; such as those to medications or their components such as Sulphur.

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Reproductive History

It is also important to understand the reproductive history of the patient. This includes whether he is a heterosexual male or otherwise, whether he is married/ widowed/ divorced, and whether he has children and how many he has.

Review of Systems (ROS)

The ROS is an important part of subjective information that must also be sought (Carlat, 2023). This is the evaluation of each and every system in the body from the viewpoint of the patient. He will be asked about every system and what he feels about that system. This will give important insight into what may be troubling the patient. For instance, he will be asked if he has gained weight recently, has experienced fever/ chills, or has been having fatigue. He will be asked if his bowel movements have changed and if he has diarrhea/ nausea, vomiting. He will also be asked about anxiety and depression and if he has polydipsia, polyuria, polyphagia, excessive sweating, heat/ cold intolerance and so on. Case Study For Old Male With Memory Loss And Urinary Incontinence

Additional Objective Information Needed

For the objective information, what needs to be gathered includes (Carlat, 2023):

Diagnostic Results

It will be important to ascertain if a number of diagnostic tests have been performed on patient H, to support an Alzheimer’s diagnosis. These include brain scans such as computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET). For the elevated blood sugars and polyuria, it is important to find out if the test HbA1c has been done to confirm type II diabetes (Lind et al., 2019). If it is between 5.7% and 6.4% he would be pre-diabetic. However, if it were found to be above 6.5% then patient H would be having type 2 diabetes. According to Thewjitcharoen et al. (2019), the sensitivity of suggested cut-off HbA1c (HbA1c ≥ 6.5%) is only 32% (95% CI 23–41%) but with high specificity of 94% (95% CI 92–96%) by using OGTT as the reference diagnosis. Case Study For Old Male With Memory Loss And Urinary Incontinence

Also to be found out if they have been done are specific diagnostic screening tools for AD. These would definitively point to the presence of the condition. They include General Practitioner assessment of Cognition (GPCOG), the three-minute Mini-Cog recall test, and the Mini-Mental State Exam or MMSE. According to Brodaty et al. (2002), the GPCOG was administered using a two-stage procedure that involved cognitive testing and, if necessary, inquiries of informants. The results showed a sensitivity of 0.85, specificity of 0.86, misclassification rate of 14%, and positive predictive value of 71.4%.

 Mental Status Examination (MSE)

Still on the objective information, the diagnosis would be helped by getting a full MSE. The inly information provided shows that the patient was found to be oriented in person and place; and disoriented in time. What is missing is the patient’s appearance at presentation, whether they have any mannerisms or tics, their speech patterns and whether they are coherent or not. Also to be found are the patient’s self-reported mood and observed affect and whether these two are congruent. It should also be found if the patient has any suicidal or homicidal ideations. If they are experiencing delusions and hallucinations this has also to be found out. Their memory has already been found to be defective. What remains is to find out their level of abstraction. Last is to find out if his insight and judgment are impaired or not. All the above would then lead to the correct DSM-5-TR diagnosis. Case Study For Old Male With Memory Loss And Urinary Incontinence

The Diagnostic Impression

Given the patient’s age (77 years), past medical history, and current presentation; it is concluded that patient H suffers from Alzheimer’s disease (AD) and type 2 diabetes mellitus (APA, 2022; Boland et al., 2021; Fazio et al., 2018; Hammer & McPhee, 2018). These can be described as follows:

  1. Alzheimer’s Disease (AD)

One of the crippling conditions of aging that result in the deterioration of brain tissue is AD. As a result, cognitive function is compromised, making it harder for the person to independently do daily tasks. This condition is highly prevalent in the US and the rest of the world, which has a significant negative impact on society, the economy, and culture (Fazio et al., 2018; Kelley et al., 2018)Case Study For Old Male With Memory Loss And Urinary Incontinence. For those with dementia caused by Alzheimer’s disease, caretakers become essential due to the incapacity to take care of themselves. A person suffering from a mental illness could lose track of when they should eat, take a bath, or use the restroom. Because they are incapable to provide care for themselves, the demented Alzheimer’s individual will basically need to rely on their caregiver to carry out necessary daily tasks. If the individual in need is receiving care at home, a caregiver may be a close relative, a certified nurse, or a nursing assistant.

            A significant portion of older individuals with dementia suffer from AD, which is identified by the presence of amyloid plaques and neurofibrillary tangles (NFTs) in the brain. Urinary incontinence (UI) is more common in the senior population and has been linked to Alzheimer’s disease patients than to people with adequate cognitive function, according to research (Bartolone et al., 2021)Case Study For Old Male With Memory Loss And Urinary Incontinence. The brain’s micturition centers may include amyloid plaques and NFTs, which could interfere with the bladder’s capacity to receive signals and cause improper voiding. Furthermore, persons with advanced Alzheimer’s disease are less likely to detect when or where to urinate or comprehend when they should.

  1. Type 2 Diabetes Mellitus (DM)

Diabetes is a chronic illness caused by the body’s incapacity to utilise its own stored insulin. This patient is obese, and obesity or excess adiposity is known to be a lifestyle factor for insulin resistance (Hammer & McPhee, 2018). Type II diabetes mellitus is the kind of diabetes that usually strikes adults later in life rather than when they are still young. Hammer and McPhee (2018) claim that Type II diabetes is fundamentally a sickness or disease of the lifestyle that is brought on by particular lifestyle choices, such as smoking, eating poorly, or not exercising enough. The HbA1c test, which gauges the amount of glycosylated hemoglobin in a patient’s blood, is the most reliable method of diagnosing diabetes (Lind et al., 2019)Case Study For Old Male With Memory Loss And Urinary Incontinence. A value above the normal range of 6.5% to 6.9% indicates a possible diagnosis of diabetes.

Differential Diagnoses and Diagnostic Tests

  1. Frontotemporal Dementia

A rare kind of dementia that impairs behavior and language is called frontotemporal dementia (APA, 2022). Challenges with mental capacities brought on by slow alterations and damage to the brain are referred to as dementia. The front and sides of the brain (the frontal and temporal lobes) are affected by frontotemporal dementia. Diagnostic tests to rule this out are the GPCOG), the Mini-Cog test, and the MMSE.

  1. Secondary Hyperglycemia

Numerous illnesses are among the secondary causes of hyperglycemia. These include hemochromatosis, pancreatic cancer, cystic fibrosis, and chronic pancreatitis, which destroy the pancreas (Hammer & McPhee, 2018)Case Study For Old Male With Memory Loss And Urinary Incontinence. Secondary hyperglycemia can also be brought on by endocrine illnesses such as pheochromocytoma, acromegaly, and Cushing syndrome, which all result in peripheral insulin resistance. The diagnostic test here is the HbA1c.

Appropriate National Guidelines to Consider

There are appropriate clinical practice guidelines to consider for dementia caused by AD. These are provided in a scholarly article by Shaji et al. (2018). The guidelines include diagnosis, treatment, and follow up. Diabetes also has clinical practice guidelines to consider. A thorough strategy to lower complications is advised in the diabetes care section (Yu et al., 2022). Therapy includes controlling blood pressure, cholesterol, and glucose levels as well as including interventions that improve the course of CVD and/or CKD.

Recommended Treatment

For patient H, the suggested medication regimen is 10 mg of donepezil (Aricept) taken orally before bed. This medication’s FDA approval for the treatment of Alzheimer’s disease and the availability of academic research supporting its safety and effectiveness serve as the basis for this decision (Stahl, 2020)Case Study For Old Male With Memory Loss And Urinary Incontinence. So as to prevent polypharmacy, he will take it as monotherapy.

            Metformin (Glucophage) is the first drug of choice for those with type 2 diabetes. This biguanide works by increasing the activity of hepatic AMP-activated protein kinase. As a result, it decreases hepatic lipogenesis and gluconeogenesis and increases the capacity of muscles to absorb glucose by means of insulin (Rosenthal & Burchum, 2020). Oral administration of 500–1000 mg pills containing it is done twice a day. Metformin is the first choice due to its suitability for patient characteristics such glycogenesis, peripheral glucose uptake, cardiac considerations, and overweight and obesity.

Health Education

Patient H should be compelled to undergo frequent examinations, take medication as needed, eat a nutritious diet, exercise frequently, get enough sleep, and abstain from potentially dangerous behaviors in order to maintain some degree of excellent mental health (Fazio et al., 2018)Case Study For Old Male With Memory Loss And Urinary Incontinence. The most important information about T2 DM concerns the side effects of metformin. It is necessary to advise the patient to report these as soon as they occur. Among them include digestive problems like diarrhea, flatulence, and nausea and vomiting. Lack of vitamin B12, skin rash, nail infection, chest pain, flushing, palpitations, headache, chills, disorientation, altered taste perception, and diaphoresis are some more symptoms (Rosenthal & Burchum, 2020). Furthermore, less than 1% of individuals get lactic acidosis, which can be fatal.

Evaluation/ Follow-Up Plan

Follow up will be after 4 weeks to reassess the patient’s cognition using the GPCOG or MMSE tests. This will show if there is any progress. The HbA1c will be done again after three months (12 weeks).

Legal and Ethical Considerations

The patient and his daughter will be allowed input into the care decisions to conform to autonomy as a bioethical principle (Haswell, 2019)Case Study For Old Male With Memory Loss And Urinary Incontinence. Confidentiality of patient information and his privacy will also be assured pursuant to the HIPAA law of 1996.

Circle of Caring

To be included in the circle of caring for patient H will be his family (his daughter), a social worker, the home visit nurse, the dietician, the physical therapist, the pharmacist, the advanced practice nurse, and a spiritual leader.

Recommended Billing Codes

  • For the monthly care management of a patient with dementia and at least one additional chronic condition, CPT code 99490 is a suitable service to employ.
  • For the diabetes testing (HbA1c), the CPT code recommended to use is

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 References

American Psychiatric Association [APA] (2022). Diagnostic and Statistical Manual of Mental Disorders-Text Revision (DSM-5-TR), 5th ed. Author.

Bartolone, S.N., Sharma, P., Chancellor, M.B., & Lamb, L.E. (2021). Urinary incontinence and Alzheimer’s disease: Insights from patients and preclinical models. Frontiers in Aging Neuroscience, 13(777819), 1-7. https://doi.org/10.3389/fnagi.2021.777819

Boland, R., Verdiun, M., & Ruiz, P. (Eds) (2021). Kaplan and Sadock’s synopsis of psychiatry, 12th ed. Wolters Kluwer.

Brodaty, H., Pond, D., Kemp, N.M., Luscombe, G., Harding, L., Berman, K., & Huppert, F.A. (2002). The GPCOG: A new screening test for dementia designed for general practice. Journal of the American Geriatric Society, 50(3), 530–534. https://citeseerx.ist.psu.edu/viewdoc/download;jsessionid=1335C2F43CEC8F5F1E85F7836F8C25F2?doi=10.1.1.600.5694&rep=rep1&type=pdf#:~:text=The%20two%2Dstage%20method%20of,positive%20predictive%20value%20of%2071.4%25 Case Study For Old Male With Memory Loss And Urinary Incontinence

Carlat, D.J. (2023). The psychiatric interview, 5th ed. Wolters Kluwer.

Fazio, S., Pace, D., Maslow, K., Zimmerman, S., & Kallmyer, B. (2018). Alzheimer’s association dementia care practice recommendations. The Gerontologist, 58(S1), S1-S9. http://dx.doi.org/10.1093/geront/gnx182

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Kelley, M., Ulin, B., & McGuire, L.C. (2018). Reducing the risk of Alzheimer’s disease and maintaining brain health in an aging society. Public Health Reports, 133(3), 1-5. https://doi.org/10.1177/0033354918763599

Lind, M., Pivodic, A., Svensson, A., Ólafsdóttir, A.F., Wedel, H. & Ludvigsson, J. (2019). HbA1c level as a risk factor for retinopathy and nephropathy in children and adults with type 1 diabetes: Swedish population based cohort study. BMJ, 366, l4894, http://dx.doi.org/10.1136/bmj.l4894

Rosenthal, L.D., & Burchum, J.R. (2020). Lehne’s pharmacotherapeutics for nurse practitioners and physician assistants, 2nd ed. Elsevier.

Shaji, K.S., Sivakumar, P.T., Rao, G.P., & Paul, N. (2018). Clinical practice guidelines for management of dementia. Indian Journal of Psychiatry, 60(Suppl 3), S312–S328. https://doi.org/10.4103/0019-5545.224472

Stahl, S.M. (2020). Stahl’s essential psychopharmacology: Prescriber’s guide, 7th ed. Cambridge University Press.

Thewjitcharoen, Y., Jones, E.A., Butadej, S., Nakasatien, S., Chotwanvirat, P., Wanothayaroj, E., Krittiyawong, S., Himathongkam, T., & Himathongkam, T. (2019). Performance of HbA1c versus oral glucose tolerance test (OGTT) as a screening tool to diagnose dysglycemic status in high-risk Thai patients. BMC Endocrine Disorders, 19(1), 1-8. https://doi.org/10.1186/s12902-019-0339-6

Yu, J., Lee, S-H., & Kim, M.K. (2022). Recent updates to clinical practice guidelines for diabetes mellitus. Endocrinology and Metabolism (Seoul), 37(1), 26–37. https://doi.org/10.3803/EnM.2022.105 Case Study For Old Male With Memory Loss And Urinary Incontinence

For this plan of care/case study, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 6-7 pages, which does not include the cover page and reference page(s).

Introduction (including purpose statement)
Case Summary or Synopsis
Include a short (75-100 word) description of the patient in terms of age, sex, race, height, weight, marital status, occupation, social/cultural history, previous hospital admissions, and chief complaint on current visit. This serves to orient the reader to the case study patient and provides an overview of clinical issues of the patient.
Discussion Questions and Answers
Conclusion
In regards to APA format, please use the following as a guide:

Include a cover page (this is not part of the 6-7 page limit)
Include transitions in your paper (i.e., headings or subheadings)
Use in-text references throughout the paper
Use double-spaced 12-point Times New Roman font
Apply appropriate spelling, grammar, and organization
Include a reference list (this is not part of the 6-7 page limit)
Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e., NCSBN, AANP)
Case Study #1:

Mr. Hendrickson is a 77-year-old man who is known to your practice. He is brought in today by his daughter, who reports a new onset of confusion accompanied by urinary incontinence. When you see the patient today, he is oriented to place and person but not time and does not recall much about events of the past few days. He says that he is eating and drinking as usual (but the daughter is shaking her head to the contrary). He denies any change in bowel function but is fearful of sleeping because he might “wet the bed.” The daughter states that he has been drinking a lot more water than usual and urinating more frequently. He denies any acute pain other than chronic arthritis. He was a regular attendee at the local senior center but has not been there for a week and seems to have forgotten about it.

Past medical history: coronary artery disease, hypertension, hyperlipidemia, elevated fasting glucose, osteoarthritis of knees.

Medications: Lisinopril 20 mg PO daily, hydrochlorothiazide 12.5 mg PO daily, metoprolol 50 mg PO daily, simvastatin 20 mg PO daily. OTC medications include Aleve, 2 tablets every 12 hours as needed for severe knee pain; topical “Icy Hot” for knee pain daily; glucosamine-chondroitin tablet daily; multivitamin “male over 50 years” daily.

Vital signs: BP 130/84; HR 60, RR 16; Temperature 99.2°F; BMI 38.

Case Study Questions:

What additional subjective and objective data would you gather?
What is the list of differential diagnoses? What additional diagnostic tests would you include to confirm or rule out each condition?
What national guidelines are appropriate to consider?
Based on your assessment and current research, what treatment would you recommend?
What else should you teach your patient? Are there any Healthy People 2030 objectives that you should consider?
What is your evaluation/follow-up plan?
Are there any legal/ethical considerations?
Using the circle of caring, what or who else should be involved to hear the patient’s voice, getting him/her and family involved in the care to reach optimal health?
What billing codes would you recommend?

Rubric points to be sure to complete:
Assessment
Develops and demonstrates a clear & precise assessment plan supported with scholarly/evidence-based. literature, and includes objective and subjective data.

Diagnostics/ Differential diagnoses
Clearly describes all appropriate diagnostic tests (including sensitivity and specificity). Thoroughly describes all relevant differential diagnoses and rationales.

Treatment plan
Develops a clearly written set of orders inclusive of all essential elements in a treatment plan with supporting scholarly/evidence-based literature and guidelines.

Evaluation/follow-up plan:
Develops and demonstrates a clear & precise evaluation/follow-up plan for the next office visit inclusive of data and target outcomes that will need to be reviewed.

Clinical Guidelines
Thoroughly describes all relevant practice guidelines. Clearly defines and delineates the levels of evidence that support the guidelines.

Health promotion/ Teaching
Develops and demonstrates a clear & precise description of the Healthy People 2030 goals and specifically relates one goal to current case.

Billing
Discusses all levels of billing, with rationale, that apply to the case and the most appropriate level for first visit and one follow up visit.

Grammar, spelling, and punctuation
APA, There are no errors in grammar, spelling, and punctuation.

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