Event 1: Meet Margaret Anderson

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.


Admission Information


Margaret Andersen


85 years old, female, widow


5 feet 4 inches

Weight Upon Admission


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


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.


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.


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


5 ft 4 inches




Is alert and responsive, laughs and giggles throughout the exam, easily distracted and confused, but pleasant and cooperative. In no acute distress.


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.


Lung sounds CTA bibasilar, no wheeze, cough, rales or rhonchi


RRR, S1S2, no murmur Gallup or rub. No JVD or carotid bruit. Radial pulse 2/4+.


Soft, non-distended, non-tender, bowel sounds normoactive


Deferred, nurses report no concerns or skin issues. Incontinent, wears briefs.


No concerns noted. Uses walker for mobility.


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


Neck is supple. Pupils equal and reactive to light. Throat is normal. No nodes in neck. No goiter. No JVD. Sinuses nontender to palpation.


No difficulty


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.


Exam unremarkable. Moving all limbs well. No untoward joint swelling.


Exam: moving all limbs well, cranial nerves unremarkable, oriented to person only. Significant loss of short term memory noted.


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 Upon Admission to Nursing Facility

Margaret's Behavior 2 Weeks After Admission

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:

Correct. Pulling on the cheek and lip can be signs of dental pain or problems in persons with dementia. Signs of dental pain problems in a dementia patient may also include: Rubbing of the face Moaning/yelling/crying Flinching when face is touched or when eating Inability to eat/drink hot and/or cold items Increased irritability Not wearing removable dental appliances

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:

Correct. Combativeness is a sign of agitation in persons with dementia. Agitation is associated with emotional distress and may increase with changes in environment, such as nursing home placement; pain or advances in stages of dementia.


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