Management of Secondary Diagnoses in the Context of Dementia

Management of Secondary Diagnoses in the Context of Dementia

Dr. Edward Perrin, MD

CareMore Touch

CASE 1

Mr. A, 74 yo, with mild Alzheimer, presents with wife to review medications. On metformin and glimepiride for diabetes, levothyroxine for hypothyroidism, lisinopril for hypertension, simvastatin for hyperlipidemia, galantamine for dementia. Is testing blood sugars once daily.

CASE 1a

Mr. A, 3½ years later, now with moderate Alzheimer presents with wife following hospitalization for shortness of breath. On same medications as above, in addition to carvedilol, diltiazem, digoxin, warfarin, and furosemide for atrial fibrillation and congestive heart failure, and insulin glargine for poorly controlled diabetes. Is testing blood sugars 3-4 times daily.

CASE 1b

Mr. A, 4 years later, now with severe Alzheimer presents with daughters after moving in with one of them after being widowered. On same medications and blood testing regimen.

CASE 2

Mrs. B, 76 yo, presents with son after ED evaluation for vaginal bleeding. Has mild dementia and chronic paranoid schizophrenia.

CASE 3

Mrs. C, 92 yo with moderate dementia, presents with group home owner for routine blood work, but also for increasing combativeness with staff. On donepezil, memantine bid, allopurinol, multivitamin, alendronate once weekly, calcium tid, vitamin D bid, chlorthalidone qod, propranolol tid, coenzyme Q10, rosuvastatin, escitalopram, methotrexate once weekly, phenytoin tid, risperidone bid, and trazodone, along with prn meds: acetaminophen, milk of magnesia, bisacodyl suppository, promethazine, risperidone, zolpidem, lorazepam, ibuprofen, triamcinolone cream, and artificial tears.

FAST (Functional Assessment of Staging of Alzheimer)

1. No difficulties, either subjectively or objectively.

2. Complains of forgetting location of objects. Subjective word finding difficulties.

3. Decreased job functioning evident to co-workers; difficulty in traveling to new locations. Decreased organizational capacity.

4. Decreased ability to perform complex tasks (e.g., planning dinner for guests), handling personal finances (forgetting to pay bills), difficulty marketing, etc.

5. Requires assistance in choosing proper clothing to wear for the day, season, or occasion.

6a. Difficulty putting clothing on properly without assistance.

6b. Unable to bathe properly; e.g., difficulty adjusting bath water temperature) occasionally or more frequently over the past weeks.

6c. Inability to handle mechanics of toileting (e.g., forgets to flush the toilet, does not wipe properly or properly dispose of toilet tissue) occasionally or more frequently over the past weeks.

6d. Urinary incontinence, occasional or more frequent.

6e. Fecal Incontinence, (occasional or more frequently over the past week).

7a. Ability to speak limited to approximately a half dozen different words or fewer, in the course of an average day or in the course of an intensive interview.

7b. Speech ability limited to the use of a single intelligible word in an average day or in the course of an interview (the person may repeat the word over and over.

7c. Ambulatory ability lost (cannot walk without personal assistance).

7d. Ability to sit up without assistance lost (e.g., the individual will fall over if there are no lateral rests [arms] on the chair).

7e. Loss of the ability to smile.

7f. Loss of the ability to hold up head independently.