Question

Case Study, Part 1 (pp. 1715–1716)

Victor Wallace is a 74-year-old Caucasian male who was diagnosed with moderate Alzheimer disease 2 years ago. Mr. Wallace lives with his 50-year-old daughter, Anne Marie, who is his primary caretaker. His wife of 52 years died of pancreatic cancer 18 months ago.

Mr. Wallace presents at his gerontologist’s office at 9:30 on Thursday morning. Ms. Wallace requested the appointment because she is concerned about the changes she has seen in her father over the past month. As the nurse working with Mr. Wallace’s gerontologist, you conduct an initial assessment and interview with Mr. Wallace and Ms. Wallace. Ms. Wallace reports that Mr. Wallace has exhibited increased confusion and anxiety at home and at the adult day care center he attends each day while she is at work.

In the past, Mr. Wallace only had these problems in unfamiliar settings. He is also experiencing a decline in language, increasingly using the wrong words to describe common objects and relying on scanning speech to find words. However, Ms. Wallace’s main concern is her father’s refusal to carry out the basic activities of daily living (ADLs) he is still capable of performing. When you ask Mr. Wallace about the ADLs, he says, “There’s no point in trying because I won’t be able to do them much longer.” As you observe Mr. Wallace, you note that he seems agitated. He is sitting on the edge of his chair, tapping his foot and rapping his hands on his knees. When you ask him basic questions, he has a hard time coming up with answers. When he can’t find the words he wants, he just repeats the phrase “That’s how it is.”

Mr. Wallace’s vital signs and weight are normal, and his physical condition is good for a man his age. You administer the Cornell Scale for Depression in Dementia and his score is 17, indicating high probability of depression. The gerontologist maintains Mr. Wallace’s current dose of 28 mg of memantine (Namenda) per day to slow the progression of his Alzheimer symptoms. She then adds sertraline (Zoloft), an SSRI, to treat his depression symptoms. Mr. Wallace is to start out taking 50 mg of sertraline per day, gradually working up to 150 mg per day over a 6-week period.

Question 1

How do your observations of Mr. Wallace correlate with the changes Ms. Wallace reports?

Question 2

What aspects of Mr. Wallace’s presentation prompt you to test him for depression?

Question 3

Why might Mr. Wallace’s increased confusion in familiar settings be a concern for Ms. Wallace?

Question 4

Why is it important to distinguish between Mr. Wallace’s refusal to perform ADLs and an inability to do so?

Question 5

Would speech therapy be an appropriate intervention for Mr. Wallace? Why or why not?

Question 6

Refer to the exemplar on Alzheimer disease in this module: How would a change in Mr. Wallace’s Alzheimer medication from an NMDA receptor antagonist like memantine to an acetylcholinesterase inhibitor like donepezil affect the doctor’s choice of SSRI for depression?

Answer 1

1. The observations I made on Mr. Wallace is that he is

• Agitated
• Tapping foot
• Rapping his hands on knees
• Can't find words
• Repeats "That's how it is"

These clearly suggests that he shows features of depression and as his daughter Ms Wallace reports his behaviour has been unusual and he is being anxious and confused is proof that he is undergoing depression. He is always sad though he has absolutely no reason to be.

2. As Mr Wallar states that "There’s no point in trying because I won’t be able to do them much longer.” He is clearly depressed. His posture(arms around knees) suggests the same. The other important sign that promp us to check for depression is that though he is physically fit to perform ADL, he is not doing so or is not interested in them.

3. Mr Wallace's increased confusion in familiar settings is a major concern as it indicates that he is losing his memory regarding the things he is close to and the severity of dementia is increasing day by day. This indicates that he is not familiar to his settings anymore and this results in unstable behaviour patterns which can include hurting himself.

4. Inability to do ADLs and refusal to perform are two different things. In the former one the person have desire to do the ADLs but is limited by inabilities or physical conditions(eg.handicap) that doesn't allow him or her to do so,while here it is a case of refusal where Mr Wallace is perfectly alright physically but is mentally not able to do the ADLs.This suggests that the problem lies in the brain(mental health is affected) and not the physical health.

5. Speech therapy does not help in this case because the patient is suffering from dementia and is not able to learn or keep in mind the things that we try to teach them. They usually forget whatever thy just heard or performed recently.

6. The change in medication from Memantine to Donepezil does not affect the choice of SSRI as sertaline is well tolerated with donepezil and was not found to have any AEs. Even combination of Memantine and donepezil is used to treat cases of severe dementia of Alzheimer's type.