MEDICAL SURGICAL NURSING

CASE VIGNETTE
(Alzheimer’s Disease)
NCM 116b

Submitted by:
MANIAGO, AIZEL D.

Submitted to:

PROF. GILEEN I. LAGADON

Clinical Instructor

May 14, 2021

I. CASE SCENARIO

A 69-year-old man is brought to his primary care physician by his wife, who
reports that his memory has failed for the past several months. She states that the
client forgets the names of friends and family members and loses his way back
home from the grocery store and that, in general, he is unable to remember new
information he acquires. Previously, he was “meticulous” about remembering his
appointments and taking his medication. Now, he has to be reminded every time
by his wife. The wife also reports that the client’s behavior is much more
disorganized – he recently put his cell phone in the freezer and his shoes in the
bathtub. His current medical problem includes hypertension, which is well-controlled
with medication.

On mental status examination, the client is alert but oriented only to person
and place. He does not remember his physician’s name, although he has seen the
same physician for more than three years. Some mild aphasia is noted, and the
patient can recall only one out of three objects at five minutes. The physician’s
working diagnosis is Alzheimer’s disease.

II. SUMMARY OF QUESTIONS AND ANSWERS

1. Based on the client’s manifestations and DSM-5 criteria, the client has what
type of neurocognitive disorder? What cognitive domains are affected in the
client?

Using the DSM-5 Diagnostic Criteria for Major Neurocognitive Disorder, the
patient satisfies the diagnosis of Alzheimer’s disease as evidenced by the following:
A. Evidence of modest cognitive decline from a previous level of performance in
one or more of the domains listed below, based on the concerns of the
individual, a knowledgeable informant or the clinician; and a decline in
neurocognitive performance. This is seen particularly in the patient as his wife
reports changes in his neurocognitive functioning. To explore more on that, the
patient has been showing the following alterations in the following cognitive
domains for the past several months:
Learning and memory. This is particularly true to the patient since he
forgets names of family, friends, and physician, his way home from the
grocery store (long-term memory), his appointments and even in taking
his medications (recent memory). Furthermore, upon assessment of the
physician, he can only recall one out of the three objects in five minutes
(immediate memory). Lastly, he not oriented to time.
Language. This is seen in the patient during the assessment of the
physician, mild aphasia being the objective cue that was observed.
Executive ability. This is true to the patient since he has generally lost
ability to remember new learning.
B. The cognitive deficits are sufficient to interfere with independence, but greater
effort, compensatory strategies, or accommodation may be required to
maintain independence. This is evidenced in the patient’s case since the
neurocognitive deficits that he is experiencing especially memory loss and
executive ability have greatly influenced his independence, losing independence
in finding his way back home and managing his medications.
C. The cognitive deficits do not occur exclusively in the context of a delirium. In
the patient’s case, the onset was gradual (several months), with evidence of
progressive deterioration, there is the presence of mild aphasia and short- and
long-term memory are impaired.
D. The cognitive deficits are not primarily attributable to another mental disorder
(for example major depressive disorder and schizophrenia). The patient is not
showing predominant mood symptoms nor marked psychosis.

2. Explain the causative factors associated with Alzheimer’s disease.

Although the specific cause of Alzheimer’s disease is not fully understood, here are
the factors that contribute to its development as according to the National Health
Association (2018):

 Age. This is the single, most significant factor. Research evidences state that the
likelihood of developing Alzheimer's disease doubles every 5 years after
reaching 65. Although this is the case, not only are the elderly are at risk of
developing the illness. This is evidenced by the occurrence of 1 in 20 people
under 65 years old developing the disease (early- or young-onset Alzheimer's
disease).
 Family history. According to Montagne, A. et.al. (2020) people with a variation
of the gene apolipoprotein E (APOE), called APOE4, have an increased risk of
developing Alzheimer’s dementia, often at an earlier age. APOE4 is known to
contribute to amyloid-β and tau accumulation (most common brain changes in
Alzheimer’s disease).
 Down's syndrome. This is because trisomy 21 which causes Down's syndrome
can also cause amyloid plaques to build up in the brain over time, which can lead
to Alzheimer's disease in some people.
 Sustained severe head injury. Although further research is need in this area, it
has been found that people who had severe head injury are at a higher risk of
developing Alzheimer’s disease.
 Cardiovascular disease. Faulty lifestyle choices such as smoking, unhealthy
eating habits, sedentary activity level, and alcohol drinking eventually lead to
cardiovascular diseases which may contribute to the accumulation of amyloid
plaques in the brain.
 Untreated depression. Thompson, D. (2014) states that due to the stress that
psychosis places on the brain, people with untreated depression and those who
have more symptoms of the disease tend to suffer a more rapid decline in
thinking and memory skills, memory being the most prominent early of
dementia.
3. What do clinicians perform to make a diagnosis of Alzheimer’s disease? What
are the diagnostic tests performed?

Several diagnostic examinations can be done to diagnose Alzheimer’s disease.

According to Melinosky, C. (2020), here are the series of diagnostic examinations
that can be done:
 Physical and neurological exam. This include testing for reflexes, muscle tone
and strength, ability to get up from a chair and walk across the room, sense of
sight and hearing, coordination, and balance. It is done particularly to determine
the extent of physical and neurological involvement and to rule out other
conditions.
 Mental status and neuropsychological testing. This test entails the evaluation
of problem-solving skills, attention span, counting skills and memory. it is done
to establish the diagnosis, evaluate the extent of cognitive impairment and serve
as a starting point to track the progression of symptoms in the future.
 Precivity AD Test. This test looks into the amounts of proteins such as beta
amyloid and Apo E in blood. The presence or absence helps determine the
probability of whether an imaging study can detect plaques in the brain and lead
to an Alzheimer’s diagnosis.
 Magnetic resonance imaging (MRI). MRI uses radio waves and a strong
magnetic field to produce detailed images of the brain. While they may show
brain shrinkage of brain regions associated with Alzheimer's disease, MRI scans
also rule out other conditions. An MRI is generally preferred to a CT scan for the
evaluation of dementia.
 Computerized tomography (CT). A CT scan, a specialized X-ray technology,
produces cross-sectional images of the brain. It's usually used to rule out other
conditions such as tumors, strokes and head injuries.

In addition to that, determining and monitoring the disease process may be

done thru these imaging studies:
 Fluorodeoxyglucose (FDG) PET scans. These show areas of the brain in which
nutrients are poorly metabolized. Identifying patterns of degeneration — areas
of low metabolism — can help distinguish between Alzheimer's disease and
other types of dementia.
 Amyloid PET imaging. This measures the burden of amyloid deposits in the
brain. In addition, it is primarily used in research but may be used if a person has
unusual or very early onset of dementia symptoms.
 Tau PET imaging. Like Amyloid PET imaging, this test measures the burden of
neurofibrillary tangles in the brain but is generally used in the research setting.
4. Based on the stages of Alzheimer’s disease, what should the client’s wife be told
to understand the course of the disease?

Based from the case of the patient, he has moderate, middle stage Alzheimer’s
disease (Stage 5: Decreased Independence). His symptoms are cross-referenced to
John Hopkins Medicine (2021), and the following symptoms coincide with the signs
under the said category: problems learning new things, inability to remember names
of family, friends and familiar people which in the case of the patient is his physician
of years now, disorientation to time, place, and proper placement of things in which
the patient placed his phone in the freezer and his shoes in the bathtub, and
wandering which in the case of the patient is that, he wandered from from the
grocery store due to his inability to recall directions.
With these findings, the client’s wife must be advised to keep the patient within
her field of vision especially when going out to prevent the patient from wandering
away which may cause safety concerns to arise. In addition to that, it must be
emphasized that one of the symptoms of this disease is the inability to learn new
things. Therefore, being patient with the client is advisable and understanding that
this is part of the disease process is equally important. Even if Alzheimer’s disease is
progressive, when the patient is disoriented, reinforcement of person, place and
time can be done. Same as through with reinforcing names of the people who are
part of his life.
Furthermore, since the patient is exhibiting late symptoms of the said stage
(inability to remember names of once familiar people and disorientation to time
and/or place), the patient’s wife must be oriented to anticipate possible occurance
of other late symptoms in this stage such as need for assistance in ADLs, emotional
instability, psychosis, restlessness, agitation, anxiousness and tearfulness especially
in late afternoon or at night which can result to sleep problems.
Finally, she is to be informed of the symptoms of severe, late stage Alzheimer’s
disorder to include loss of physical abilities (walking, sitting, eating), loss of bowel
and bladder control, loss of ability to start and sustain a conversation, unawareness
to recent experiences and surroundings, and total dependency with ADLs.

5. What management can be done for the client? Describe each component of
management concisely.

According to the Guideline for Alzheimer’s Disease Management by the

California Workgroup on Guidelines for Alzheimer’s Disease Management (2008),
Cholinesterase Inhibitors such as donepezil, galantamine, and rivastigmine are used
to treat Mild, Moderate and Severe Alzheimer’s disease. In addition to that, NMDA
antagonists such as memantine can be used to treat Moderate to Severe Alzheimer’s
disease.
A. donepezil
Generic name: donepezil hydrochloride
Therapeutic class: Anti-Alzheimer drugs
Pharmacologic class: Acetylcholinesterase inhibitors
Mechanism of Action: Inhibits acetylcholinesterase, the enzyme that causes
acetylcholine hydrolysis, resulting in increased acetylcholine available for synaptic
transmission in the CNS.
Desired effect: Slowed disease progression.

B. galantamine
Generic name: galantamine hydrobromide
Therapeutic class: Anti-Alzheimer drugs
Pharmacologic class: Acetylcholinesterase inhibitors
Mechanism of Action: Enhances cholinergic action by increasing acetylcholine level
in the brain by slowing the degeneration of acetylcholine.
Desired effect: Slowed disease progression.

C. rivastigmine
Generic name: rivastigmine
Therapeutic class: Anti-Alzheimer drugs
Pharmacologic class: Acetylcholinesterase inhibitors
Mechanism of Action: Increases acetylcholine level by inhibiting cholinesterase
enzyme, which causes acetylcholine hydrolysis.
Desired effect: Slowed disease progression.

D. memantine
Generic name: memantine hydrochloride
Therapeutic class: Anti-Alzheimer drugs
Pharmacologic class: N-methyl-D-aspartate receptor antagonists
Mechanism of Action: Antagonizes N-methyl-D-aspartate receptors, the persistent
activation of which seems to increase Alzheimer symptoms.
Desired effect: Slowed disease progression.

Aside from pharmacologic interventions, therapeutic management such as usic,

dancing, pet- or animal-assisted therapy, aromatherapy, and multisensory
stimulation can be done to maximize the patient’s involvement with the
environment and enhance his quality of life (Cho, 2018; Yackimicki, Edwards,
Richards, & Beck, 2019 as cited by Videbeck).
In addition to promoting his quality of life by his exposure to his environment, a
therapy namely Reminiscence therapy can be done. The process involves the family
in the care of the patient. Moreover, this is a treatment that uses all the senses —
sight, touch, taste, smell and sound — to help individuals with dementia remember
events, people and places from their past lives. Not only will this therapy help the
client but it allow the family to reminisce their memories with the patient as well
(Geller, 2017).
Lastly, the patient may also be referred to Community-Based Services. This is a
generic term for services provided outside of a hospital setting, usually in clinics or
surgeries, which are provided to support an individual living in his/her own home, or
to support his/her carer. Given the increasing structure, support, and personal
assistance needed by the patient with Alzheimer’s Disease as cognitive impairment
worsens, adult day care is one of the best care settings for the mid-stage individual
living in the community.

6. Considering the manifestations of the client, formulate one nursing diagnosis.

Chronic confusion related to neuronal degeneration as manifested by inability to

remember home directions and names of family, friends and physician (long-term
memory), forgetting appointments and medication management (short-term
memory), mild aphasia and inability to remember new learning.
 References

California Workgroup on Guidelines for Alzheimer’s Disease Management. (2008).

Guideline for Alzheimer’s Disease Management.
https://www.alzheimersla.org/wp-content/uploads/2016/01/Professionals-Guid
eline-FullReport-CA.pdf

Geller, F. H. (2017, October 27). Benefits of reminiscence therapy. Senior Living

Communities in California - Elder Care Alliance.
https://eldercarealliance.org/blog/benefits-reminiscence-therapy/

John Hopkins Medicine. (2021). Stages of Alzheimer's disease. Johns Hopkins

Medicine, based in Baltimore, Maryland.
https://www.hopkinsmedicine.org/health/conditions-and-diseases/alzheimers-d
isease/stages-of-alzheimer-disease

Melinosky, C. (2020, July 29). Making the diagnosis of Alzheimer's disease. WebMD.
https://www.webmd.com/alzheimers/guide/making-diagnosis-tests

Montagne, A., & et.al. (2020, May 19). Alzheimer’s gene contributes to blood-brain
barrier breakdown. National Institutes of Health (NIH).
https://www.nih.gov/news-events/nih-research-matters/alzheimers-gene-contri
butes-blood-brain-barrier-breakdown

National Health Association. (2018, May 10). Alzheimer's disease - Causes. nhs.uk.
https://www.nhs.uk/conditions/alzheimers-disease/causes/

Thompson, D. (2014, July 30). Scientists shed light on link between depression,
dementia. WebMD.
https://www.webmd.com/depression/news/20140730/scientists-shed-light-on-l
ink-between-depression-dementia

Videbeck, S. L. (2020). Psychiatric-Mental Health Nursing (8th ed.). Wolters Kluwer.

Wilkins, L. W. (2020). Nursing2021 drug handbook. Lippincott Williams & Wilkins.