The goal of this course is to provide an interactive learning experience about an 85 year-old woman who has limited communication living at a nursing homes who has difficulty with activities daily living due to her limited verbal communication.
In this module, you will learn about Margaret Andersen, and how her case progresses through a series of events at the Meadow Lane Nursing Facility.
History
Admission Information
Name
Margaret Andersen
Demographics
85 years old, female, widow
Height
5 feet 4 inches
Weight Upon Admission
142
Social History
Church member – very active until 2 years ago, hobbies were cooking, painting and reading, walking her dog, visits with friends and church members, playing bridge
Occupation/Employment
Retired librarian – retired at age 68 University of Iowa CoEPE Older Adult With Limited Communication
Living Environment
Prior to nursing home, she lived at home alone; single family residence with help from her grandson.
Location
Small town in Iowa – Nursing Home placement was the only option – no assisted living or memory care units available.
Family History
Has one son and daughter in-law who travel 6 months of the year (November to April) to Texas. Adult grandson lives in town and visits once per week at nursing home.
Functional Status/Activity Level
Ambulates independently – has fallen 1 time in the last 2 weeks in the bathroom at nursing home with bruising to her left arm and leg. Ambulatory in facility, minimal assistance w/ADL activities. Interacts with residents and other staff.
Communication
She is able to speak however has dysphagia; answers to questions but answers do not make sense or answer the question asked.
Past History
Past Medical History
Cardiovascular disease with hyperlipidemia, atrial fibrillation, rheumatoid arthritis, osteoporosis, dementia diagnosis 5 years ago, dentures.
Admission to Nursing Home
Patient had been living at home with assistance of grandson. Two weeks ago, she wandered away from home and was unable to be found for 8 hours. She was eventually found wandering in the park 2 miles from home. Due to safety concerns, she was admitted to the nursing care facility.
Review of Systems
Vital Signs
112/72 60 18 T97.0
Admission Weight
142 lb
Height
5 ft 4 inches
BMI
24.4
Orientation
Is alert and responsive, laughs and giggles throughout the exam, easily distracted and confused, but pleasant and cooperative. In no acute distress.
HEENT
Normocephalic, skin intact, no lesions visible. Unable to assess EOM d/t distractibility, PEARLA, conjunctiva clear. CN not tested. Hearing intact to normal speaking voice. No lesions observed. Thyroid palpable without nodules, trachea midline. No lymphadenopathy or tenderness.
Chest
Lung sounds CTA bibasilar, no wheeze, cough, rales or rhonchi
Heart
RRR, S1S2, no murmur Gallup or rub. No JVD or carotid bruit. Radial pulse 2/4+.
Abdomen
Soft, non-distended, non-tender, bowel sounds normoactive
GU
Deferred, nurses report no concerns or skin issues. Incontinent, wears briefs.
MS
No concerns noted. Uses walker for mobility.
Skin
Reported to be intact, nurses report no pressure ulcers or lesions. Braden 17. Uses static air SS in wheelchair.
Physical Exam
Alert, oriented to self only. Good appetite. Slightly hard of hearing
Endocrine
Neck is supple. Pupils equal and reactive to light. Throat is normal. No nodes in neck. No goiter. No JVD. Sinuses nontender to palpation.
Lung
No difficulty
Heart
Sounds S1, S2 normal; no S3, no S4, no murmurs. Chest clear to IPPA with good air entry bilaterally and no adventitious sounds heard. Abdominal exam reveals positive bowel sounds, soft, nontender to palpation all quadrants, no masses, no organomegaly, no guarding and no rebound.
Genitourinary and Rectal
Exams deferred.
Musculoskeletal
Exam unremarkable. Moving all limbs well. No untoward joint swelling.
Neurologic
Exam: moving all limbs well, cranial nerves unremarkable, oriented to person only. Significant loss of short term memory noted.
Medication
Aspirin 81 mg 1 tablet orally daily
Calcium carbonate 600 mg 1 tablet orally three times per day
Vitamin D3 400 units one tablet orally twice daily
Donepezil 10 mg one tablet orally daily at bedtime
Memantine 10 mg one tablet orally twice daily
Metoprolol 50 mg one tablet orally twice daily
Simvastatin 20 mg one tablet orally daily in the evening
Quetiapine 50 mg one tablet orally daily
Acetaminophen 325 mg two tablets orally every 4 hours as needed
Senna-S 8.6-50 mg one tablet orally twice daily as needed
Tools at Admission
Pain Assessment in Advanced Dementia (PAINAD) Score: 0 Mini-Cog™ is attempted but didn’t complete it due to Margaret’s limited communication.
Current Problems
On this screen, there are two videos, one at the admission, and the second is two weeks after admission to the facility.
Margaret's Behavior Upon Admission to Nursing Facility
Margaret's Behavior 2 Weeks After Admission
PAINAD and Mini-Cog™ Tools
When Margaret was admitted to the facility she was assessed for pain and cognition. Due to her dementia and limited communication, the Pain Assessment in Advanced Dementia assessment (PAINAD) was used for pain and her score was a 0. The Mini-Cog™ was attempted for cognition but was unable to be completed due to her limited communication.
At two weeks following admission, the PAINAD was repeated. Her PAINAD score had changed to 2, indicating pain. Margaret is unable to communicate her pain or a pain location. On the PAINAD tool, all other elements were scored as a zero with normal breathing, no negative vocalizations, and inexpressive facial expression.
As you saw in the last video, Margaret is easily distracted by voice or touch, combative and agitated when interacting with staff.
Test Your Knowledge: Recognize Behavior Changes
Being able to recognize the possible source of behavior change might be useful in helping you to make a treatment plan for Margaret. Read the scenario and select the answer for the behavior changes in each case.
Scenario 1
A 76 year old male was recently placed in nursing home care 4 days ago. In the last 3 days, he has refused to eat. What might be the source of his behavior change? [Select all that apply]:
Refusal to eat may come from a variety of reasons: not liking the food, frustration with eating, pain, changes in environment or people with nursing home placement, or changes in dementia.
Scenario 2
In the last 5 days, a nursing home resident has started pulling on her check and lip. She does this at different times during the day. What might be the source of her behavior change? Select the best answer:
Scenario 3
An 83 year old female was placed in a nursing home in the last week. She has begun being combative with caregivers and nursing staff. What might be the source of her behavior change? Select the best answer:
