CEJN 144 Intro to Blogging - Psychotic Disorder

Mrs. B, an 85-year-old woman, presented to the Emergency Department with her son with increased paranoia, visual hallucinations, and agitation. Her son had taken her to her GP when facility staff reported the symptoms, but Mrs B. angrily accused the GP of trying to euthanase her. The GP encouraged the son to take her to ED and he would fax a referral.

She moved to an assisted living facility and did well there until she was hospitalized 2 years ago with agitation. At that time, she was diagnosed with late onset Alzheimer’s type dementia with delusions, depressed mood, and behavioural disturbance. She returned to the assisted living facility and was stable until a few months before her current hospitalization, which was precipitated by gradually worsening paranoid delusions, visual hallucinations, severe restlessness, and difficulty in being redirected.

According to her son, Mrs. B had had "strange thoughts" for as long as he could remember. For example, for a time, Mrs. B would eat only foods that were white. Still, in her adult life, she had actively participated in developing and running a successful family business with her husband and had raised two sons. When her husband died 5 years ago, Mrs. B developed a major depressive disorder, single episode, severe with psychotic features.

1. After reviewing the information available, what other information needs to be gathered at this point?

2. What are the important immediate issues?

3. With this minimal information, what do you think may be happening with Mrs B.?

4. How should the health service respond?

1. This case study represents the case of Mrs. B who is a 85 year old woman suffering from increased paranoia, visual hallucination, and agitation with a strong allegation of the general physician trying to euthanase her. During her previous hospitalization three years ago, she had been diagnosed with late onset Alzheimer’s type dementia with delusions, depressed mood, and behavioural disturbance. The case study also indicates that the working symptoms of the patients had been deteriorating and as a result she had worsening paranoid delusions, visual hallucinations, severe restlessness, and difficulty in being redirected. Her son had confessed that she had strange thoughts from as long as he could remember and her mental condition has worsened considerably after the death of her husband five years ago which led her to develop a major depressive disorder with psychotic symptoms.

It has to be mentioned that the case study is successful in providing a preliminary insight on the condition of the patient, however, for a working diagnosis to be completed so that treatment interventions can be provided, there is need for more extensive information(Stowell et al., 2012).In this case, a thorough past medical history with exact account of her previous medical illnesses and the medication or treatment that she had undergone will be required. Along with that a family history analysis of any plausible mental illness will be beneficial input to be added into the patient data. General observation of the patient is often the gateway to obtaining a preliminary understanding of the stage of psychosis as a part of general information. Mental state examination involving 15 elements to assess the mental state and cognitive functioning followed by a direct patient interview will be required(Sink et al., 2015).

2. There are various concerns that are prevalent in this case scenario for the patient under consideration. For instance, it has to be mentioned that she had been suffering from many symptoms of psychosis along with her worsening dementia. As per the case study information, she had presented in the health care facility with the complaint of the general physical trying to euthanase her and had been very anxious, agitated and restless. Hence, the paranoia and deteriorating delusions or hallucination from the worsening dementia is one of the greatest medical priorities or concerns for Mrs. B(Martin et al., 2014). her agitation and aggressiveness that she has demonstrated is a huge risk to her health and her as well as anyone around her. The impact of agitation and restlessness or irritability in a mentally ill older adult can lead to severe consequences such as violence and self-harming tendencies, hence, it is also a grave issuer for the patient to consider. Lastly, for patients with immense psychological symptoms and depressive disorders, the risk of suicidality is also extremely high. Hence, as Mrs B is also suffering from deteriorating dementia, possible onset of psychosis with worsening paranoia and delusions along with depression, the risk for suicidality and self-harm is also a considerable risk for her and is an important health issue(Stowell et al., 2012).

3. It has to be mentioned that the diagnosis of any psychotic disorder is a long and complicated procedure and involves a variety of different factors and assessment data. The psychotic symptoms that a mental patient suffers from is inherently unique for the patient, although there is a link between the psychotic symptoms corresponding to the different psychotic symptoms, the extent of clinical manifestations is individualized for each patient(Maust et al., 2017). Hence, for a proper working diagnosis of the mental disorder an extensive range of assessment and patient interviewing is required. However, in this case, the case information provides an array of information, proper analysis of which can provide a chance of assuming the possible mental health condition that the patient under consideration is in.

As per the case information, the patient had been diagnosed with late onset Alzheimer’s type dementia with delusions, depressed mood, and behavioural disturbance. Although she had been progressing the living facility, her symptoms started deteriorating further and developed more complicated symptoms such as the gradually worsening paranoid delusions, visual hallucinations, severe restlessness, and difficulty in being redirected. In this case it can be assumed that the burden of the dementia and depression had been delimiting on her and the loss of her husband had a major impact on her already deteriorating cognitive health(Martin et al., 2014). The major clinical manifestations that Mrs B had been exhibiting had been agitation, delusions, paranoia and confusion. On an elaborative note, she had been adamant and restless when admitted to the health care facility with the complaint of her general physician trying to euthanase her which indicates at deteriorating delusions. As per her symptoms and the information that is available about her, the patient seems to be suffering from signs of psychosis developed from her deteriorating dementia, delusions and depression(Maust et al., 2017).

4. In light of the presenting symptoms that the patient in the case study is suffering from, the health service will need to respond in a holistic manner addressing not just the mental health needs of the patient but also the overall physical, emotional and spiritual needs of the patient(Bowling &Iliffe, 2006). In order to address to her psychosis symptoms and her deteriorating dementia she will need to be assessed and treated by a neurology special and psychotherapist. Along with then pharmacological interventions, she will also need the assistance of cognitive behavioural therapies, mindfulness based therapies and related other psychotherapeutic assistance. However, the health service addressing to the health issues of the patient ill also need to consider the impact of aging in her life(Bowling & Dieppe, 2005). Successful aging is a process that involves various modifications and coping, hence the approach taken for Mrs B will also need to incorporated person centred and holistic successful aging models. There are various models of successful aging such as Rowe and Kahn’s model of successful aging, SOC model, lay model, and graceful aging model which can be incorporated into the care planning and implementation procedure to ensure optimal health and wellbeing status and dignified living for the aging patient(Wang, Chen &Shie, 2013). However, as Mrs.B is coping with the loss of her husband and the resultant psychotic disorders, the life-span model of Selective Optimization with Compensation model (SOC-model) that focuses on biological, psychological, and socio-economic changes and learn to compensate for the losses, this model might be best suited for her(Ouwehand, de Ridder&Bensing, 2007).

References:

Bowling, A., & Dieppe, P. (2005). What is successful ageing and who should define it?. Bmj, 331(7531), 1548-1551.

Bowling, A., &Iliffe, S. (2006). Which model of successful ageing should be used? Baseline findings from a British longitudinal survey of ageing. Age and ageing, 35(6), 607-614.

Martin, P., Kelly, N., Kahana, B., Kahana, E., Willcox, B. J., Willcox, D. C., & Poon, L. W. (2014). Defining successful aging: A tangible or elusive concept?. The Gerontologist, 55(1), 14-25

Maust, D. T., Kales, H. C., McCammon, R. J., Blow, F. C., Leggett, A., &Langa, K. M. (2017). Distress associated with dementia-related psychosis and agitation in relation to healthcare utilization and costs. The American Journal of Geriatric Psychiatry, 25(10), 1074-1082

Ouwehand, C., de Ridder, D. T., &Bensing, J. M. (2007). A review of successful aging models: Proposing proactive coping as an important additional strategy. Clinical psychology review, 27(8), 873-884

Sink, K. M., Craft, S., Smith, S. C., Maldjian, J. A., Bowden, D. W., Xu, J., ...& Divers, J. (2015). Montreal cognitive assessment and modified mini mental state examination in African Americans. Journal of aging research, 2015

Stowell, K. R., Florence, P., Harman, H. J., & Glick, R. L. (2012). Psychiatric evaluation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA Psychiatric Evaluation Workgroup. Western Journal of Emergency Medicine, 13(1), 11

Stowell, K. R., Florence, P., Harman, H. J., & Glick, R. L. (2012). Psychiatric evaluation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA Psychiatric Evaluation Workgroup. Western Journal of Emergency Medicine, 13(1), 11

Wang, K. M., Chen, C. K., &Shie, A. J. (2013). GAM: a comprehensive successful ageing model. Theoretical Issues in Ergonomics Science, 14(3), 213-226.