Collaborative Care in Nursing Practice A Case Presentation Dementia

There is no conflict of interest that may have a direct bearing on the subject matter of this presentation.

Mary Ritchie, R.N., B.Sc.N. Seniors Mental Health Capital Health Mental Health Program

How Many Specialists Does One Patient Need? Brief clinical and family history Brief clinical and family history Overview of care providers involved Overview of care providers involved Rural health care Rural health care Community Mental Health Nurse role Community Mental Health Nurse role Client update Client update How many specialists does this patient need How many specialists does this patient need

Cognitive Impair Functional Disability Problem Behaviours Family/ Informal Care Family Physician Neurology Home Care Nova Scotia Seniors Mental Health Assessor Care Givers Psych. Nursing Assess Psychiatrist Psych. Fellow Fellow Nursing Home Staff Geriatrician In-Patient Admission Palliative Care Adult Protection Neurology Family Physician Family Nursing Home Staff Geriatrician Client

Initial Home Assessment 60 yr old male, neatly dressed, watchful, anxious 60 yr old male, neatly dressed, watchful, anxious Speech slowed, delayed response to questions, flat affect, does not initiate conversation Speech slowed, delayed response to questions, flat affect, does not initiate conversation No evidence of psychosis No evidence of psychosis Low mood Low mood Slowed gait, no falls reported; continent with cuing; feeds himself Slowed gait, no falls reported; continent with cuing; feeds himself Drinks rum; recently stopped smoking cigarettes Drinks rum; recently stopped smoking cigarettes

Recognizes memory loss and feels sad and angry Recognizes memory loss and feels sad and angry On interview no intention to harm self or others On interview no intention to harm self or others Feels helpless but not hopeless Feels helpless but not hopeless Yells because he’s frightened and angry Yells because he’s frightened and angry Wants someone with him 24/7 Wants someone with him 24/7 Will go to nursing home, feels he needs help Will go to nursing home, feels he needs help MMSE 14/30 GDS 7/30 MADRS 10/60 MMSE 14/30 GDS 7/30 MADRS 10/60

Collateral Lives in son’s house; on a main road and has water frontage with a wharf Lives in son’s house; on a main road and has water frontage with a wharf Strong outdoorsman; good relationships Strong outdoorsman; good relationships Glass installer: disability pension 6 years Glass installer: disability pension 6 years Wife managed things for him Wife managed things for him Wife died two years ago Wife died two years ago Brother shot himself several years ago (90’s) Brother shot himself several years ago (90’s)

Collateral (Current ) Accepts help from HCNS and family Accepts help from HCNS and family Needs prompting or full care for ADL Needs prompting or full care for ADL Not able to manage IADL (sons have PA) Not able to manage IADL (sons have PA) Rapid change in memory and function over past two years Rapid change in memory and function over past two years Stopped smoking two weeks ago (AP) Stopped smoking two weeks ago (AP) Drinks rum weekly (Hx heavy drinking) Drinks rum weekly (Hx heavy drinking) Not physically aggressive; verbally aggressive, threats of self harm Not physically aggressive; verbally aggressive, threats of self harm

Medical History Hypertension Hypertension Diabetes Diabetes Hypercholesterolemia Hypercholesterolemia Positional vertigo Positional vertigo Smoker Smoker Heavy alcohol consumption (HX) Heavy alcohol consumption (HX) Remote history of Bells Palsy Remote history of Bells Palsy Episodes of blacking out since 96 Episodes of blacking out since 96

Diagnosis Difficulty with mental functioning Difficulty with mental functioning Mild cerebral atrophy Mild cerebral atrophy (L) carotid stenosis (L) carotid stenosis 2000 No evidence of progressive dementia 2000 No evidence of progressive dementia 2001 Parkinson’s disease 2001 Parkinson’s disease 2004 Alzheimer’s disease 2004 Alzheimer’s disease 2005 Alzheimer’s disease (possibly mixed with vascular dementia) 2005 Alzheimer’s disease (possibly mixed with vascular dementia)

Medications Vitamin E 400 IU od Vitamin E 400 IU od Novasen 325 mg od Novasen 325 mg od Aricept 10 mg od Aricept 10 mg od Allopurinol 200 mg od Allopurinol 200 mg od Lipitor 10 mg od Lipitor 10 mg od Nadolol 80 mg od Nadolol 80 mg od Glyburide 5 mg od Glyburide 5 mg od Seligilne 5 mg od Seligilne 5 mg od Novoamilor 50 mg am Novoamilor 50 mg am Clonazepam 0.25 mg hs Clonazepam 0.25 mg hs

Family Two adult male caregivers Two adult male caregivers Grandmother, mother, father Grandmother, mother, father XX X X X ?dementia (02) cancer (03) dementia C suicide

Rural Care Health Beliefs Rural Rural Role performance (health as function) Role performance (health as function) Do what you can do Do what you can do Seek help when you can no longer do Seek help when you can no longer do Continue usual actions Continue usual actions Consider medical advice Consider medical advice Urban Urban Medical model (absence of disease) Treat symptoms Seek R for Sx Follow medical advice

Mixed Model Couple sought medical help Couple sought medical help Dad can’t live alone, we’ll move him Dad can’t live alone, we’ll move him Dad can still go out on Tuesday and have a rum Dad can still go out on Tuesday and have a rum We can’t do all the care, HCNS We can’t do all the care, HCNS This is the limit of our ability This is the limit of our ability Local nursing home Local nursing home Continued family involvement Continued family involvement

Community Mental Health Nurse Role Identify health beliefs of client and family Identify health beliefs of client and family Recognize strengths/capacity Recognize strengths/capacity Facilitate communication Facilitate communication Assessment (collaborative) Assessment (collaborative) Identify options Identify options Support formal and informal caregivers Support formal and informal caregivers Support local resources Support local resources Close the case Close the case

Client’s Current Status Lives in local nursing home Lives in local nursing home No longer able to ambulate No longer able to ambulate Recently recognized a friend who visited Recently recognized a friend who visited Had a birthday party and requested Had a birthday party and requested ‘a beer’……..so he had one ‘a beer’……..so he had one Meds: Allopurinol 200 mg od Meds: Allopurinol 200 mg od Vitamin D 1000 IU od Vitamin D 1000 IU od Ranitidine 150 mg bid Ranitidine 150 mg bid Rispiridone 1 mg am and hs Rispiridone 1 mg am and hs

Cognitive Impair Functional Disability Problem Behaviours Family/ Informal Care Family Physician Neurology Home Care Nova Scotia Seniors Mental Health Assessor Care Givers Psych. Nursing Assess Psychiatrist Psych. Fellow Fellow Nursing Home Staff Geriatrician In-Patient Admission Palliative Care Adult Protection Neurology Family Physician Family Nursing Home Staff Geriatrician Client

How Many… 1. Family Physician 2. Neurologist 3. Geriatrician 4. Home Care Assessor 5. Home Support Staff 6. Community Mental Health Nurse 7. SMHS Psychiatrist 8. Fellow SMHS 9. Fellow SMHS 10. Geriatrician (admission) 11. Consult to Neurology 12. Palliative Care Physician 13. Nursing Home Staff