Neurocognitive Case Study Workshop Paper – Part 1

Margaret Johnson, an 82-year-old retired nurse who lives alone, has undergone a deterioration in her condition over the past few days; she was confused and agitated and saw things that were not there. Her history of hypertension, diabetes, and osteoporosis necessitates neurocognitive evaluation. The clinical diagnosis in this case is delirium with Alzheimer’s disease and Lewy body dementia considered in differential after accounting for variable symptoms: Neurocognitive Case Study Workshop Paper – Part 1.

Neuroanatomy of Delirium

Delirium primarily affects the prefrontal cortex, thalamus, and basal ganglia, which are crucial for attention, executive function, and awareness. The reticular activating system in the brain stem is responsible for the state of wakefulness and is usually abnormal in delirium. Pathophysiologic changes involved in the development of delirium include a decrease in the levels of acetylcholine neurotransmitters and increased levels of dopamine neurotransmitters, hence resulting in inattention and altered perception, which are the cardinal features of delirium.

Research has also indicated that delirium is accompanied by cortical abnormalities, which cause impaired thought processing and hallucination (Stollings et al., 2021). Further, structural imaging studies suggest that delirium involves aberrant connectivity of the brain as mediated by default mode network (DMN) for conscious and cognitive functioning.

Physiological and Mental Status Examination Findings

Physiological Examination

Margaret Johnson’s vital signs are stable, with a blood pressure of 130/82 mmHg, heart rate of 82 bpm, respiratory rate of 18, and temperature of 98.9°F. Physical neurological assessment reveals normal cranial nerves and absent abnormalities of motor weakness and reflexes. Clinical examination of the cardiovascular and pulmonary systems is normal. Nevertheless, she has slightly tender palpable modules in her pelvic region, increased frequency of urination, and urinary incontinence.

Mental Status Examination (MSE)

Physiological assessment findings play an important role in the diagnostic process when addressing neurocognitive disorders. Margaret has no alterations in her vital signs, with blood pressure 130/82 mmHg, pulse rate 82 beats per minute, respiratory rate 18 breaths, and temperature 98.9 ℉. Sensation in the face is normal; cranial nerves are normal. There are no focal neurological deficits, reflexes are normal, there are no abnormal movements, and there is no evidence of limb weakness or tremor, ruling out primary neurological disorders like stroke (Mevorach et al., 2022).

MSE findings further support the diagnosis of delirium. She appears anxious and restless, sometimes agitated, and has impaired attention, solving serial sevens and other cognitive tasks. She is also disoriented and has issues with time and spatial relations, as seen when she could not remember where she was.

She denies other symptoms yet reports hearing and seeing things that are not there, “I saw people dancing on my bed.” She complains of memory loss, cannot think clearly, and meets diminished insight and judgment, meaning higher-order cognitive processing has been affected. These symptoms are not consistent and are more like delirium than a progressive neurocognitive disorder.

Cultural, Spiritual, and Biopsychosocial Considerations

Cultural & Spiritual Factors

Margaret mentioned her religious background as Catholic and even used Lent as one of the examples, meaning that faith plays a role in the well-being of this subject. Belief systems could affect her response to the treatments and the role of family in the making of decisions regarding her care. Also, the African American group records a higher incidence of neurocognitive disorders, and therefore, interventions should be culturally appropriate.

Biopsychosocial Factors

Margaret’s family situation is quite good; she has two adult children who often come to visit her. By evaluating her level of social contribution, her current reduced social activity shows potential cognitive deterioration. Her family history of Alzheimer’s increases her risk of neurodegenerative disorders.

Recommended Diagnostic Testing

To confirm delirium and rule out differential diagnoses, the following diagnostic workup is recommended:

Recommended Diagnostic Testing

To affirm the diagnosis in the case of delirium, clinical and laboratory tests have to be conducted to eliminate neurocognitive disorders. The baseline and follow-up laboratory tests include CBC and CMP because metabolic disturbance, infection, or dehydration can cause delirium. In light of this, blood glucose and hemoglobin A1C tests are appropriate for Margaret, involving her history of diabetes, because diabetes has an effect on cognition due to fluctuations in blood sugar. Further, Vitamin B12, folate, and thyroid profile will help exclude the other causes of cognitive decline that may be treatable.

As the presence of UTIs is known to cause delirium in elderly patients, the examination should include a urinalysis and a urine culture. An MRI or CT scan is useful in diagnosing tumors, strokes, or abnormalities within the structure of the brain. Further, some of the screening tools that would be of great importance in assessment and monitoring include the Confusion Assessment Method (CAM) for delirium, the Montreal Cognitive Assessment (MoCA) for cognitive impairment, and the Delirium Rating Scale (DRS-98) for symptom severity.

Primary Diagnosis: DeliriumBottom of Form

Delirium is an acute neurocognitive disorder characterized by a sudden onset of symptoms, as seen in Margaret Johnson, whose confusion began two days ago. The condition is unsteady and has alternating phases of clarity and confusion. She displays distractibility and inattention, as seen through a lack of focus during serial sevens.

Further, symptoms like seeing people dancing on her bed are also indicative of this diagnosis. Also, she presented symptoms such as increased activity, insomnia, and the possibility of having a high risk of a UTI or a metabolic abnormality that caused her change in mental status.

Differential Diagnoses

Lewy Body Dementia (LBD)

LBD is a progressive neurocognitive illness with fluctuating cognition, visual hallucinations, and Parkinsonian motor features (neuroanatomy). It results from abnormal deposits of the alpha-synuclein protein (Lewy bodies) in the brain, affecting the dopaminergic and cholinergic systems (physiological assessment findings). Autonomic impairment, sleep disturbances, and prominent neuropsychiatric symptoms occur in the patients (psychiatric assessment findings).

Unlike Alzheimer’s, LBD presents with early hallucinations and fluctuating cognition, which may manifest as delirium. This disease is relatively more common in the African American population; thus, culturally appropriate interventions and early diagnosis should be encouraged (cultural considerations). Spiritual delusions can occur in a few patients, with the requirement for sensitivity in treatment (spiritual considerations).

The prognosis for LBD is progressive impairment in cognition and functions, with a median survival of 5–8 years since the onset of symptoms (disorder prognosis). The disease fluctuates over its course, and there is a need for continuous symptomatic treatment and supportive care to maintain the quality of life (bio-psychosocial considerations) (Breijyeh & Karaman, 2020).

Alzheimer’s Disease (AD)

Alzheimer’s disease (AD) is a progressive neurocognitive syndrome with gradual impairment in cognition and compromised daily functions. It is associated with cortical atrophy, most prominent in the hippocampus, leading to impairment in memory and executive functions (neuroanatomy). Unlike delirium, though, AD is characterized by gradual cognitive impairment with no fluctuation in awareness. Physiologic features are diminished memory, confusion, and impairment in activities of daily living (ADLs) (physiological assessment findings) (American Psychiatric Association, 2022).

Psychiatric symptoms are apathy, depression, and poor judgment (psychiatric assessment findings).  The disease is more prevalent in African American populations, which highlights the importance of early detection and culturally responsive care (cultural considerations). Spirituality plays a role in long-term care planning, with patient and family preferences guided by it.

Margaret’s familial history of AD places her at risk, which necessitates continuous monitoring of her cognition (bio-psychosocial considerations). The prognosis is irreversible, with long-term supportive care required to control progressive symptoms while maintaining quality of life (disorder prognosis).

Prognosis for Margaret Johnson

The prognosis depends on the underlying cause of delirium. If identified and treated early, delirium can be fully reversible. However, older adults with delirium are at a higher risk for developing dementia. Given her family history of AD, Margaret will require long-term cognitive monitoring.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Breijyeh, Z., & Karaman, R. (2020). Comprehensive review on Alzheimer’s disease: Causes and treatment. Molecules, 25(24), 5789. https://doi.org/10.3390/molecules25245789

Mevorach, L., Forookhi, A., Farcomeni, A., Romagnoli, S., & Bilotta, F. (2022). Perioperative risk factors associated with increased incidence of postoperative delirium: systematic review, meta-analysis, and grading of recommendations assessment, development, and evaluation system report of clinical literature. British Journal of Anaesthesia, 23(47). https://doi.org/10.1016/j.bja.2022.05.032

Stollings, J. L., Kotfis, K., Chanques, G., Pun, B. T., Pandharipande, P. P., & Ely, E. W. (2021). Delirium in critical illness: Clinical manifestations, outcomes, and management. Intensive Care Medicine, 47(10), 1089–1103. https://doi.org/10.1007/s00134-021-06503-1

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Purpose
This assignment allows students to evaluate, contrast, research, and present the neurocognitive disorder assigned to them. The student will be assigned one of the available case studies from this assignment at the beginning of the course. The student will evaluate the case study to determine the diagnosis for the client.

Based on the client’s diagnosis, the student will explore the neuroanatomy, physiological examination, mental status examination, clinical presentation, differential diagnosis, and treatment of the assigned topic. This paper is broken down into sections each week, ending with a presentation in week three of the course.

Part One – Module One

• The student will work individually on the assignment.
• The entire paper is completed on the case study assigned to the student at the beginning of the course.
• Part one of the paper should be three to five pages long (not including title/reference pages), using the current APA formatting requirements with appropriate grammar and spelling.
• The paper requires at least four peer-reviewed resources, one of which may be the DSM-V-TR.
• All peer-reviewed resources used in the paper should be less than five years old.
  

  Neurocognitive Case Study Workshop Paper – Part 1

Part One of the paper must include:

• Title page in APA format
• Brief opening description of the neurocognitive disorder suspected
• Neuroanatomy of the neurocognitive disorder
• Physiological and mental status examination assessment findings for the neurocognitive disorder
• Cultural, spiritual, and biopsychosocial factors to consider for the neurocognitive disorder
• Diagnostic testing recommended for the neurocognitive disorder, including screening tools
• Formulation of the primary diagnosis for the client with two differential diagnoses. The student must provide detailed information that supports the primary diagnosis and a rationale for each of the two differential diagnoses, contrasting the features of these disorders with those of the primary diagnosis.
  • When comparing and contrasting your differential diagnoses, make sure to address the following components for each:
    • neuroanatomy
    • physiological assessment findings
    • psychiatric assessment findings
    • cultural considerations
    • spiritual considerations
    • bio-psychosocial considerations
    • disorder prognosis
• Anticipated prognosis for the client
• Reference page with all references in APA format

Resources:

• Stahl, S. M. Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications
• DSM-5-TR  text