A 74-year-old African American woman, Ms. Richardson, was brought to the hospital emergency room by the police. She is unkempt, dirty, and foul-smelling. She does not look at the interviewer and is apparently confused and unresponsive to most of his questions. She knows her name and address, but not the day of the month. She is unable to describe the events that led to her admission.
The police reported that they were called by neighbors because Ms. Richardson had been wandering around the neighborhood and not taking care of herself. The medical center mobile crisis unit went to her house twice but could not get in and presumed she was not home. Finally, the police came and broke into the apartment, where they were met by a snarling German shepherd. They shot the dog with a tranquilizing gun and then found Ms. Richardson hiding in the corner, wearing nothing but a bra. The apartment was filthy, the floor littered with dog feces. The police found a gun, which they took into custody. The following day, while Ms. Richardson was awaiting transfer to a medical unit for treatment of her out-of-control diabetes, the psychiatric provider attempted to interview her. Her facial expression was still mostly unresponsive, and she still didn’t know the month and couldn’t say what hospital she was in. She reported that the neighbors had called the police because she was “sick,” and indeed she had felt sick and weak, with pains in her shoulder; in addition, she had not eaten for 3 days. She remembered that the police had shot her dog with a tranquilizer and said the dog was now in “the shop” and would be returned to her when she got home. She refused to give the name of a neighbor who was a friend, saying, “he’s got enough troubles of his own.” She denied ever being in a psychiatric hospital or hearing voices but acknowledged that she had at one point seen a psychiatrist “near downtown” because she couldn’t sleep. He had prescribed medication that was too strong, so she didn’t take it. She didn’t remember the name, so the interviewer asked if it was Thorazine. She said no, it was “allal.” ‘Haldol?”, ask the interviewer. She nodded.
The interviewer was convinced that was the drug, but other observers thought she might have said yes to anything that sounded remotely like it, such as “Elavil.” When asked about the gun, she denied, with some annoyance, that it was real and said it was a toy gun that had been brought to the house by her brother, who had died 8 years ago. She was still feeling weak and sick, complained of pain in her shoulder, and apparently had trouble swallowing. She did manage to smile as the team left her bedside.
Answer the following using APA 7, and 500 words:
Remember to answer these questions from your textbooks and clinical guidelines to create your evidence-based treatment plan. At all times, explain your answers.
Summarize the clinical case including the significant subjective and objective data.
Generate a primary and two differential diagnoses. Use the DSM5 to support the assessment. Include the DSM5 and ICD 10 codes.
Discuss a pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.
Discuss non-pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.
Describe a health promotion intervention that would be appropriate for this patient.
ADVANCED PRACTICE PSYCHIATRIC NURSING
Kathleen R. Tusaie, PhD, PMHCNS/NP-BC, is a professor at the University of Akron and has been in private practice since 1988. Dr. Tusaie is certified as a psychiatric-mental health clinical nurse specialist and psychiatric nurse practitioner by the American Nurse Credentialing Center. She holds certificates in advanced pharmacology, multicultural nursing, eye movement desensitization and reprocessing (EMDR), psychoneuroimumunology, brief psychotherapy, cognitive behavioral therapy (CBT), clinical hypnosis, and Bowen family therapy. In addition to the University of Akron, she has taught at the University of Pittsburgh and Pennsylvania State University School of Nursing. Her research has focused on the concept of resilience and she has published and presented internationally. Dr. Tusaie has been the principal investigator or co-principal investigator in five funded research projects and has received many awards and honors.
Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN, is Elizabeth Brooks Ford Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University (CWRU) in Cleveland, Ohio, where she was dean from 1982 through 1997. She holds an adjunct position as professor, Department of Geriatrics, Mount Sinai School of Medicine, New York, New York. She earned a BSN (Georgetown University), an MS in psychiatric-mental health nursing (the Ohio State University, Columbus), a PhD in nursing (New York University), and an MBA from CWRU. Dr. Fitzpatrick has received numerous honors and awards; she was elected a fellow in the American Academy of Nursing in 1981 and a fellow in the National Academies of Practice in 1996. She received the American Journal of Nursing Book of the Year Award 18 times. Dr. Fitzpatrick is widely published in nursing and health care literature. She served as co-editor of the Annual Review of Nursing Research series, volumes 1–26; she edits the journals Applied Nursing Research, Archives of Psychiatric Nursing, and Nursing Education Perspectives, the official journal of the National League for Nursing. She has published several books with Springer Publishing Company, including three editions of the classic Encyclopedia of Nursing Research (ENR).
ADVANCED PRACTICE PSYCHIATRIC NURSING
Integrating Psychotherapy, Psychopharmacology, and Complementary and Alternative Approaches Across the Life Span
Kathleen R. Tusaie, PhD, PMHCNS/NP-BC Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN
Clinical Case Summary:
Ms. Richardson, a 74-year-old African American woman, was brought to the emergency room by the police due to her wandering around the neighborhood and neglecting her personal hygiene. Upon arrival, she appeared unkempt, dirty, and unresponsive to most questions. She demonstrated confusion and was unable to recall the events leading to her admission. She exhibited memory deficits, such as not knowing the day of the month. The police had to break into her apartment where they encountered a hostile German shepherd, which they tranquilized. Ms. Richardson was found hiding in a corner, wearing only a bra, and the apartment was filthy with dog feces scattered on the floor. A gun was discovered and confiscated by the police. During the interview, Ms. Richardson’s facial expression remained unresponsive, she still had difficulty recalling the month, and she was unaware of the hospital’s name. She reported feeling weak, experiencing shoulder pain, and not eating for three days. She denied any previous psychiatric hospitalization or hearing voices but mentioned seeking help for insomnia and being prescribed “allal,” which the interviewer understood as Haldol. Ms. Richardson also denied the gun being real, claiming it was a toy left by her deceased brother. She complained of weakness, sickness, shoulder pain, and swallowing difficulties, although she managed to smile as the team left her bedside.
Based on the provided information, the primary diagnosis for Ms. Richardson would be Neurocognitive Disorder due to probable Alzheimer’s disease (DSM-5 code: 331.0; ICD-10 code: G30.9). The clinical presentation indicates significant cognitive impairment, including memory deficits, confusion, unresponsiveness, and difficulty recalling recent events. The deterioration in personal hygiene and self-care, along with impaired judgment and insight, further support this diagnosis.
Delirium due to a general medical condition (DSM-5 code: 293.0; ICD-10 code: F05.9): Delirium may present with similar symptoms of confusion, cognitive impairment, and disorientation. However, in Ms. Richardson’s case, the prolonged duration of symptoms and chronicity suggest a more likely diagnosis of neurocognitive disorder.
Major Depressive Disorder with cognitive features (DSM-5 code: 296.33; ICD-10 code: F33.2): Depressive disorders can manifest with cognitive impairment, including memory deficits. However, Ms. Richardson’s symptoms are more consistent with a neurocognitive disorder, given the severity of cognitive decline and associated functional impairment.
Considering the probable diagnosis of Neurocognitive Disorder due to Alzheimer’s disease, the recommended pharmacological treatment would involve the use of cholinesterase inhibitors. According to clinical guidelines (APA Practice Guideline for the Treatment of Patients with Alzheimer’s Disease and Other Dementias), medications such as donepezil (Aricept) or rivastigmine (Exelon) are the first-line options for managing cognitive symptoms in Alzheimer’s disease. These medications can help stabilize or slow the progression of cognitive decline by increasing acetylcholine availability in the brain. The choice between these medications would depend on individual patient factors, medication tolerability, and potential drug-drug interactions.
Non-pharmacological interventions play a crucial role in managing neurocognitive disorders. For Ms. Richardson, the following non-pharmacological treatments would be appropriate:
Cognitive Stimulation Therapy (CST): CST is a structured program involving group activities and discussions designed to enhance cognitive function and promote social engagement. This therapy has shown effectiveness in improving cognitive abilities, quality of life, and overall functioning in individuals with neurocognitive disorders.
Environmental Modifications: Creating a safe and supportive environment is essential for individuals with cognitive impairment. This includes minimizing clutter, ensuring good lighting, using calendars and memory aids, and implementing strategies to prevent wandering or accidents.
Health Promotion Intervention:
A health promotion intervention that would be appropriate for Ms. Richardson is caregiver education and support. Educating and providing support to her caregivers, such as family members or friends, can enhance their understanding of the disease, coping strategies, and ways to provide appropriate care. This intervention aims to alleviate caregiver burden, improve the quality of care provided to Ms. Richardson, and promote overall well-being for both the patient and the caregivers.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
American Psychiatric Association. (2019). Practice Guideline for the Treatment of Patients with Alzheimer’s Disease and Other Dementias, 3rd Edition. Arlington, VA: American Psychiatric Association Publishing.
Tusaie, K. R., & Fitzpatrick, J. J. (Eds.). (2023). Advanced Practice Psychiatric Nursing: Integrating Psychotherapy, Psychopharmacology, and Complementary and Alternative Approaches Across the Life Span (2nd ed.). Springer Publishing Company.