Dementia
Patient Presentation
CC was an 82 year-old female admitted to the orthopedics inpatient unit due to a fracture of her left ankle. Her vitals were stable, and had a past medical history of type 2 diabetes, hypertension, and hyperlipidemia. CC was living in a nursing home, and had fallen down some stairs. The patient had 2 middle-aged daughters, who had been unable to care for her increased needs due to progressive dementia. CC consistently exhibited difficulty with short-term memory, inability to care for herself, episodes of frustration, stubbornness, and violent outbursts. They stated she also was more accident prone, and had several incidences of falls.
Her daughters were at the bedside throughout her stay, with the exception of night-time. During the day, CC was generally pleasant. Medications and instructions had to be reinforced several times by the nurses and her family. After her ORIF procedure (open reduction internal fixation), CC became increasingly confused during the night and kept attempting to get up out of bed-which was not recommended due to her post-surgical status (perineural catheters, and Foley were also in place). She was alert, awake and oriented to person. When asked where she was, CC stated she was at home and had no idea who we (staff) were, and to “leave me alone and get the hell out of my house”. Staff tried to frequently reorient her, explaining she was in the hospital, had fallen and broken her ankle, and had her look at the cast on her leg. We explained she could not get up at this time and the rationale. She then began yelling her husband’s name, calling for him to help her and then tried to kick the staff with her casted leg. (Her husband had passed away several years back). We stated that her youngest daughter would be here early in the morning and her eldest later in the day, as they were previously. Both had spoken to her on the phone before bed. CC stated that her youngest daughter was still a child, and would not be able to drive over to see her or use the phone.
Differentials
Sundowning
Diagnosis
CC had been diagnosed with progressive dementia about 8 years prior. Blood tests were used to rule out other disorders causing her symptoms. She will continue to struggle cognitively
Treatment
A sitter was to be with CC for the rest of the night. Valium® was ordered for CC and allowed her to sleep. CC was treated medically and per protocol for her ankle fracture. Her dementia was not treated clinically, but staff approached her treatment with increased patience, reorientation, and did not argue with the patient. When CC would refuse a needed medication, we would ask the family if we could come back at a later time to give it in attempt to see if she would be more receptive. The majority of times that approach would work, as she had forgotten the previous interaction and being upset.
Outcome
CC went back to her nursing home with physical therapy services.
Case created by Crystal Chappell, 2011.