ࡱ> pro5@ =bjbj22 (dXX|%+ H \ dddd4d\ B        "B$B$B$B$B$B$B$gDRFHB>;"*  e""HB  ]B2$$$"4  "B$;""B$*$9$<>  `CBd"X\=A,B<Bv=MG#MG4>\ \ >MG A ^$ L6!   HBHB\ \ #\ \ M1PBL C4 2007 Caring for Junior Part I Fred A. Roberts, 54, brought his father, Fred R. Roberts, Jr., for a new patient visit. (When Fred A. Roberts outgrew the name Freddie, he became Fred and his dad agreed to go by Junior. Though Junior is now 82 years old, the nickname stuck.) Junior is alert and pleasant. He says, Its nice to see you again. You look well. Junior is dressed nicely, yet his black dress shoes are scuffed and his blue three-piece suit fits loosely and has several scattered food stains. When asked directly, Junior offers little information about his medical history. With further questioning, he becomes annoyed and finally points to his son saying, Ask him the questions. Hes Mr. Know-it-all.  Fred expresses general concerns about his fathers health; including an estimated 30-pound weight loss since last year, and memory problems for about 3-4 years. Junior can recall his wartime service & name of his high school, but is often mixed up about recent events, and asks frequently about a brother who died last year. Junior quit going to Wednesday night church suppers about a year ago. Fred takes his dad to lunch and rates his dads appetite as excellent. Junior performs ADLs by himself, but he does require assistance with bathing. He needs help with most IADLs. He still drives and manages his medications. Junior never smoked or drank alcohol, and lives alone in an apartment, though Fred checks on him daily. Junior denies being anxious, but complains of being tired because he gets up too early. Junior complains about missing his late wife and mentions he is worth more dead than alive. Junior doesnt recall his medications and Fred remembers only the three blood pressure pills (atenolol, Dyazide, and lisinopril). Despite his medications, Junior was hospitalized twice recently for hypertension and weakness. Both hospitalizations were brief and Junior was discharged on only one pill. You ask Junior to put on a gown as you step out of the room. M1PBL C4 2007 Caring for Junior Part II When you leave the room, Fred follows you out. Fred is worried about his fathers driving and will no longer ride in the car when his dad drives. Junior had an accident four weeks ago near the city center. Junior was not injured but was cited for failure to yield. Fred tells you that hes stressed out dealing with his dad and may have to put him in a nursing home. Minutes later, you re-enter the room. Junior is still fully dressed, holding the gown in his hands. Fred extends his hand to his dad and asks for his jacket, which Junior hands him. Fred asks for subsequent clothing items, one at a time, by name. Soon, Junior is undressed and gowned. Junior is 5 feet 7 inches tall, and weighs 124 pounds. He requires help up onto the examination table. His sitting blood pressure is 178/80 (L) and 180/74 (R) and pulse is 82. His pupils are equally round and reactive to light. His extra-ocular movements are intact. On fundoscopic examination, the discs are sharp, without gross hemorrhages or exudates. The cardiovascular examination reveals has a regular carotid upstroke, a normal S1 and S2, and an S4 with a holosystolic murmur medial to the apex with radiation to the axilla made louder with handgrip. The PMI is laterally displaced. Lungs are clear. The abdominal examination is normal. You find no lymphadenpopathy. There is slight pitting edema of both lower extremities to the mid-calf. Vibratory sensation is decreased. Strength is intact throughout. Muscle stretch reflexes are present and equal, except for absent ankle jerks. He has no tremor or bradykinesia, but some rigidity. His gait is slow, a bit shuffling, with some unsteadiness in turning. His affect is flat. Junior, who completed high school, scores 18/30 on the Folstein Mini-Mental State examination (MMSE) and 8/15 on the Geriatric Depression Scale (GDS). You order some laboratory studies. You provide Fred with a medication box and instruct him on its use. Fred provides you with a copy of Juniors Living Will along with his Durable Power of Attorney for Healthcare that designates Fred as his proxy. You note that both were completed 5 years ago. You suggest to Fred that he should consider initiating the process for guardianship of his father. M1PBL C4 2007 Caring for Junior Part III The next day Juniors lab results return. His electrolytes are unremarkable except for his BUN of 22 with a creatinine of 1.3. Calcium, CBC, RPR, TSH, and B12 level are unremarkable as well. In the late afternoon you receive a page from the Emergency room. The emergency physician wants to inform you about Junior, who arrived at the hospital by ambulance. She reports that Juniors son found him down on the floor in his apartment. According to Fred, Junior looked fine the prior evening when Fred went over his house to fix Juniors dinner and arrange his medications. This afternoon when Fred went to check on Junior, he found his father on the floor. He had no focal weakness, but had been incontinent. When Fred tried to help his dad up to his feet, he mumbled and fell out again. Fred tried to sit Junior up, but he was less coherent sitting. Fred called 911. His initial blood pressure by the EMS was 70/palpation with a slow, thready pulse. In the ambulance, Junior said that he did not fall, but he that he felt bad and just decided to sit down on the floor. Fred had brought all Juniors medicines in a bag. They included: Furosemide 20 mg po bid Potassium chloride 16 mEq po q am Atenolol 100 mg po q am Lisinopril 20 mg daily Darvocet N-100 Q4-6 hrs prn pain Diazepam 5mg po qhs prn for sleep Oxybutynin 5 mg PO BID Paroxetine 20 mg dailyValium 10 mg PO qhs prn Aspirin 325 mg po daily Tenormin 50 mg PO daily Lasix 40 mg PO daily Terazosin 5 mg po QHS Fosamax 35 mg po weekly Donepezil 10 mg po QHS M1PBL C4 2007 Caring for Junior Part IV Juniors blood pressure in the ER rose to 110/60 with fluids. His breathing is normal, with a respiratory rate of 12. Juniors EKG shows left bundle branch block. His color looks good and without cyanosis, his conjunctiva are pink. There is no evidence of trauma. Junior has no pelvic or hip pain. His range of motion about the hip is normal. His labs show no sign of dehydration or anemia. You agree with the emergency physician, and admit Junior to the hospital to rule out a heart attack. A head CT scan shows ventricular enlargement with atrophy consistent with the patients age. The hospital staff pulls an EKG from 2 years previous that showed LBBB also. On admission, Junior gets no medications for blood pressure. The next morning his blood pressure is up to 160/74. Because Junior is wandering in the halls at night he is given diphenhydramine 50 mg po for sleep and additionally receives haldol 5 mg IM stat and twice daily orally by the hospital physician. Juniors blood tests show that he did not have a CK (Creatine Kinase) bump or elevated troponin. Additionally, a chest x-ray and an expanded metabolic panel were normal. His telemetry monitor shows no arrhythmias. Three days later you get an urgent call from Fred. He went to the hospital to pick up Junior, but found that he has great difficulty walking, and requires a wheelchair to get as far as the door of his room. Junior seems lethargic and a bit more confused. He doesnt see how his father will be able to go back to his apartment alone. You page the hospital physician to discuss the situation. PT and OT are consulted, and though it takes two more days Junior is discharged to a sub-acute rehabilitation facility. M1PBL C4 2007 Caring for Junior Part V Junior recovers some function, but Fred does not believe he can return home and convinces Junior to be discharged directly to an assisted living center. You talk with the physician in the Rehabilitation center and learn that Fred is now taking only atenolol 50 mg po daily; paroxitine 10 mg daily; vitamin E; donepezil 10 mg daily, and aspirin 325 mg daily. At your follow-up visit with Junior 2 weeks later you learn that Junior had a difficult adjustment at the assisted living facility at first, sometimes shouting at other staff members and residents. After the first week though, he seemed to do better. According to Fred the facility staff enjoys Junior, and takes a personal interest in him. They note that Junior seems more confused in the morning, but does better after breakfast. The staff also reports that he has sundowning at times. Junior often complains to the staff of being tired. One time he told a staff member that his life is not worth living. M1PBL C4 2007 Caring for Junior Part VI Fred suggests, and Junior agrees, to an increase in the paroxetine. Fred also provides you with documentation that he has been appointed as legal guardian for his father. After 6 weeks of paroxetine at 20mg daily, Junior seems more interactive, but still says hes tired. He participates in more group activities at the facility, and he continues to go out weekly with his son for lunch. His son says that Junior laughs a lot more than he used to do. Juniors weight increases to 130 pounds. Junior renews his interest in the cheeseburgers and chocolate malts at the citys last remaining drive-in.  Fred becomes very involved in the local Alzheimers Association and is participating in a study of Pittsburgh Compound B at the local medical center. Many individuals face the dual responsibility of caring for growing children and parents/older relatives Many providers fail to recognize signs of cognitive impairment because of intact social graces Observational clues of poor grooming (inattention to detail), weight loss Deflecting questions, appointing others to answer questions, changing subjects, using humor/anger to cover The differential diagnosis for his weight loss includes ominous diagnoses such as malignancy, but it is common for dementia patients at home alone to lose weight from malnutrition. Impairment in short-term memory and long term memory Impairments in work or social activities Decline from functional level before illness Many medication issues in older adults (foreshadowing) Driving safety is important to address and often overlooked Many Caregivers are stressed with important implications for them and the patient Adults with cognitive impairment may require structured assistance to be capable of greater functioning Blood pressure taken while sitting with finding of hypertension confirmed, taken in both arms Evidence of mitral regurgitation Examination not completely normal, but no Parkinsonian features suggestive of Lewy body dementia or focal evidence of old CVA Normal MMSE >=23 for those with a high school education Normal GDS < 6 Advance Directives are of two types and both are underutilized. The three most likely causes of reversible dementia are: medications; depression; and metabolic abnormalities. There is no evidence of metabolic issue causing dementia. TSH and B12 testing may likely show abnormalities, but replacement therapy is unlikely to have a significant positive impact on cognition. The utility of syphilis testing in patients with isolated dementia is questionable. New medical issues typically occur in the context of multiple chronic conditions Wide range of possibilities for found down is a new set of hypotheses on top of hypotheses for memory loss Ridiculous, but this is actually simplified from Juniors real medication list! How does this happen? Fragmented healthcare usually. The sedative-hypnotic valium (also listed as # 6- diazepam) and the oxybutynin, an anticholinergic agent, are likely to negatively impact cognition. What are the odds he was really supposed to be taking all of this stuff? None. This is important because patients may be started on what they were prescribed, rather than what they where actually taking, when admitted to the hospital. There are 6 medications in this regimen that will lower blood pressure, including lasix listed twice (once listed as # 1- furosemide). Common, but prevents discernment of MI from EKG Pretty common finding Inappropriate medications and doses for this patient. The diphenhydramine is particularly troublesome, as a strongly anticholinergic agent So no real explanation for spell besides polypharmacy effects Functional Decline is just one of many hazards of hospitalization Another set of hypotheses is needed here to explain why he is functionally worse. And who arranges this? The Social Worker usually. If Junior was poor he would likely have to got to a nursing home or possibly a personal care home Treated for HTN, Dementia and depression. Common in Dementia Dementia & Depression coexist and are typically chronic It is important to identify target symptoms or behaviors that will be used to judge response to antidepressant therapy. Fatigue, in particular, is a symptom experienced equally by depressed and non-depressed older individuals and may not change with therapy. Personal grooming, appetite, and participating in groups may have improved for Junior. What did Junior have? Not clear. Likely a combination of dementia, depression, medication non-compliance, inadequate living situation. Perhaps other things. Several radiotracers with high affinity to beta amyloid plaques have been developed for the purposes of in vivo human imaging using PET to identify preclinical pathologic changes. This could be a great benefit to researchers. You may want to ask the group why?       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