1. The Worried Sailor Anxiety Case

2. Presentation 84-year-old Navy veteran with long history of dementia 84-year-old Navy veteran with long history of dementia About a week ago began pacing, ringing his hands, looks distressed, cannot focus on any conversation About a week ago began pacing, ringing his hands, looks distressed, cannot focus on any conversation When asked what’s wrong says “I don’t know” When asked what’s wrong says “I don’t know” Family visits help some in reducing anxiety Family visits help some in reducing anxiety

3. Medical History Lung disease Lung disease Heart disease Heart disease High blood pressure High blood pressure Left knee replacement Left knee replacement Arthritis Arthritis Enlarged prostate Enlarged prostate History of skin cancer History of skin cancer Constipation Constipation Urinary incontinence Urinary incontinence

4. Medications Oxygen Oxygen Atrovent Atrovent Metoprolol Metoprolol Acetaminophen Acetaminophen Ultram Ultram Flomax Flomax Aricept Aricept Namenda Namenda Colace Colace Senna Senna

5. Recent Changes No environmental changes No environmental changes Same roommate Same roommate Staff the same Staff the same Family visits regularly and when called Family visits regularly and when called No health downturns noted No health downturns noted No ER or hospital visits No ER or hospital visits No new medications or treatments No new medications or treatments

6. Medical Assessment Examination unchanged Examination unchanged Lung function Lung function Oxygen saturation stable Oxygen saturation stable Laboratory Laboratory All tests are normal All tests are normal No falls No falls Pain scale scores are fine Pain scale scores are fine No depression No depression

7. Medical Management Lung medications Lung medications May cause some anxiety, unfortunately May cause some anxiety, unfortunately Worry about use of benzodiazepines in lung disease (alprazolam, lorazpam, clonazepam) Worry about use of benzodiazepines in lung disease (alprazolam, lorazpam, clonazepam) May slow breathing May slow breathing Could cause confusion, falls Could cause confusion, falls Use very low dose Use very low dose Buspirone may be added Buspirone may be added No falls, sedation, confusion or breathing problems No falls, sedation, confusion or breathing problems Takes weeks to work, however Takes weeks to work, however

8. Nursing Management Patient routinely exercised by walking with staff every two hours when awake Patient routinely exercised by walking with staff every two hours when awake Sleep chart kept overnight to assess for insomnia Sleep chart kept overnight to assess for insomnia Patient encouraged to be involved in activities that he enjoys, such as recalling his days in the navy Patient encouraged to be involved in activities that he enjoys, such as recalling his days in the navy Staff involve the resident in calm, repetitive activities like folding towels and shining silverware Staff involve the resident in calm, repetitive activities like folding towels and shining silverware

9. Nursing Management Use brief simple relaxation exercises or muscle relaxation Use brief simple relaxation exercises or muscle relaxation Have patient avoid stimulants, especially caffeine Have patient avoid stimulants, especially caffeine Reassess environmental stimuli Reassess environmental stimuli Dining area, large groups Dining area, large groups Too isolated Too isolated Evaluate for delusions that cause fear Evaluate for delusions that cause fear Food is poisoned, family all died Food is poisoned, family all died

10. Outcome Only as needed anxiety reducing medication added Only as needed anxiety reducing medication added Exercise, activity with staff helped Exercise, activity with staff helped Enjoyed dusting furniture in the day room. Enjoyed dusting furniture in the day room. Having more trouble remembering family visits Having more trouble remembering family visits He feels they have abandoned him He feels they have abandoned him Put sign in sheet in room Put sign in sheet in room Family happy to call to calm him down Family happy to call to calm him down Anxiety greatly reduced Anxiety greatly reduced