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NRNP 6665 Diagnosing, and Treating Patients With Neurocognitive Disorders

NRNP 6665 Diagnosing, and Treating Patients With Neurocognitive Disorders

Neurocognitive disorders (NCDs) such as delirium, dementia, and amnestic disorders are more prevalent in older adults. As the population ages and as life expectancy in the United States continues to increase, the incidence of these disorders will continue to increase. Cognitive functioning in such areas as memory, language, orientation, judgment, and problem solving are affected in clients with NCDs. Caring for someone with a neurocognitive disorder is not only challenging for the clinician; it is stressful for the family as well. The PMHNP needs to consider not only the patient but also the “family as patient.” Collaboration with primary care providers and specialty providers is essential. Anticipatory guidance also becomes extremely important.

There is no Assignment due this week. You should review this week’s Learning Resources and consider the insights they provide about assessing, diagnosing, and treating neurocognitive disorders. Use this quiet week to work on your practicum assignment if you are taking both courses concurrently.

NRNP 6665 Diagnosing, and Treating Patients With Neurocognitive Disorders

My mother used to be a teacher—an elementary school teacher. We were all so proud of her when she completed her PhD when she was 50. Now she is 75 and has begun to have times when she does not know what day it is. We found her wandering around the neighborhood because she could not find her way home. Once, she forgot where she parked her car at the grocery store. She thought someone had stolen it. The manager was so kind to drive her around the parking lot until she recognized her car. We are afraid she might get hurt or lost.

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—Gary, age 50, son of Dorothy, age 75

Neurocognitive disorders are unique among the other psychiatric disorders you have studied in that they “are syndromes for which the underlying pathology, and frequently the etiology as well, can potentially be determined” (DSM-5, 2013). That is, diseases or injuries are to blame for the neurocognitive manifestations. These conditions are acquired and (in contrast to neurodevelopmental disorders) represent a decline from a previous higher level of functioning. Neurocognitive disorders present a diagnostic challenge for the PMHNP in that many of the signs and symptoms overlap.

Subjective:

CC (chief complaint): Sarah Higgins is a 9-year-old female who has been brought to the clinic with complaints of having difficulties in sitting for meals alongside paying attention to classwork and social activities. The primary care provider noted that Sarah does not get proper nutrition.

NRNP 6665 Diagnosing, and Treating Patients With Neurocognitive Disorders

HPI: Sarah Higgins is a 9-year-old female who has been brought to the clinic with history of having difficulties in paying attention to classwork and social activities. The client started experiencing the above problems when she joined kindergatten. The report given by the teacher shows that Sarah is largely inattentive in class. Sarah easily forgets what she it taught in class and is easily distractible. Sarah also pays minimum attention to activities such as reading. Sarah is also highly forgetful. She easily misplaces things and finds it difficult in locating them. Sarah also often daydreams. She however pays moderate attention to the things that she likes. Her mothr reported that besides the challenges in school, Sarah also shows similar issues at home. The attention and behavioral problems have persisted since Sarah’s childhood.

Past Psychiatric History:

  • General Statement: Sarah does not have any history of mental illness.
  • Caregivers (if applicable): The mother confirms the above complaints by the teacher regarding Sarah’s behavior. Her mother reports that the symptoms have persisted since Sarah’s childhood. The symptoms worsen when Sarah is participating in group activities then when she engages in individual tasks.
  • Hospitalizations: Sarah has no history of hospitalization.
  • Medication trials: Sarah has no history of medication trials for the management of her symptoms.
  • Psychotherapy or Previous Psychiatric Diagnosis: Sarah has no history of engagement in psychotherapy or previous psychiatric diagnosis.

Substance Current Use and History: There is no history of current or previous history of substance abuse by Sarah or her family.

Family Psychiatric/Substance Use History: There is no history of psychiatrict or substance abuse in Sarah’s family.

Psychosocial History: Sarah is a 9-year-old student. Sarah currently lives with her grandmother since her parents are separated. Sarah’s developmental milestones are up to date. Since birth, Sarah has exhibited problems in concentrating or paying attention to details. Sarah has also had the challenge of sitting for meals. Her primary care provider noted that Sarah does not getting adequate nutrition. The current history shows that Sarah does not have any history of child abuse, trauma, physical or emotional abuse. Sarah’s performance in school is below that of her peers. She experiences challenges in contentrating, recalling, and relating with her peers. As a result of the above, she has been referred to the clinic for further assessment and management of her symptoms.

Medical History: no history of admission, treatment, and vaccination are up to date.

 

  • Current Medications: none
  • Allergies: no-known history of drug or food allegery
  • Reproductive Hx: no significant reproductive history

ROS:

  • GENERAL: The client appears alert, with no evidence of weight loss, fever, chills or fatigue
  • HEENT: The client denies headache, hearing loss, ear ache, eye drainage, tinnutis, losse of body balance, lymphadenopathy, or difficulties in breathing
  • SKIN: The client denies itching and skin rash or changes in skin color
  • CARDIOVASCULAR: The client denies chest pain, tighteness, palpitations, or edema
  • RESPIRATORY: The client denies difficulty in breathing, wheezing, cough, or shortness of breath
  • GASTROINTESTINAL: The client denies nausea, vomiting, diarrhea, or changes in her appetite
  • GENITOURINARY: The client denues dysuria or changes in the color or smell of urine
  • NEUROLOGICAL: The client denies headache, numbness, loss of balance, changes in level of consciousness, or tingling of the extremities
  • MUSCULOSKELETAL: the client denies joint pains or muscle weakness
  • HEMATOLOGIC: The client denies history of bleeding
  • LYMPHATICS: The client denies lymphadenopathy
  • ENDOCRINOLOGIC: the client denies heat or cold intolerance

Objective:

Physical exam: Vitals: Temperature 97.4, p-62, r-14, bp-95/60, ht 4’5 Wt-63lbs

Diagnostic results: Connect Teacher Rating Scale-Revised completed by the teacher showed that Sarah is inattentive to class activities, easily distracted, forgets things easily, and poor in reading, spelling as well as arithmetic. The results further demonstrated that Sarah has short attention span in class and social activities, pays attention to the things that she likes, and easily distracted alongside lacking interest in school work. The teacher also reported that the Sarah starts things but never finishes them and seldom follows instructions (Fumeaux et al., 2020). Sarah confirmed the above as reported by her teacher.

Assessment:

Mental Status Examination: Sarah is appropriately dressed for the occasion. She has developmental milestones that are appropriate for her age. The affect of Sarah was bright. Sarah denied any visual or auditory hallucations. She however daydreams. Sarah denued any paranoid thought processes. Sarah’s mood was euthymic. The concentration was grossely intact. Sarah’s insight was intact.

Differential Diagnoses: Attention deficit hyperactive disorder, predominantly inatenttive type, developmental disorder, anxiety disorder, and autism.

The primary diagnosis for Sarah is attention deficit hyperactive disorder, predominantly inattentive type. Children with attention deficit hyperactive disorder present with symptoms of ADHD alongside symptoms of inattention in children aged less than 17 years (Sharma et al., 2020). Children also exhbit symptoms of hyperactive impulsivity. Sarah’s symptoms that align with the above diagnosis include reduced ability to pay attention, reduced cognitive processing and responding abilities, and daydreaming. Children with the diagnosis also present with symptoms such as making careless mistakes, failing to follow through assigned tasks, difficulties in organizating tasks, and loses or misplaces objectives easily (Sadek et al., 2020). Sarah has the above symptoms, hence, the primary diagnosis of attention deficit hyperactive disorder, predominantly inattentive type.

The second differential diagnosis for Sarah is development disorder. Children with developmental disorders may present with symptoms that are closely related to those of attention deficit hyperactive disorder. For example, the children may have symptoms such as intellectual disability, behaviors, and gitedness that are often within the normal range of the level of development for a children. However, developmental disorders do not cause impairment in the functioning of the child. For example, children with development disorders do not show symptoms such as reduced attention span, occupassional impulsivity, and increased motor activity (Zhang & Gatzke-Kopp, 2020). Therefore, it is the least likely diagnosis for Sarah since she has symptoms of impaired function.

The third differential diagnosis for Sarah is anxiety disorder.  Anxiety is an emotional disorder that may be associated with symptoms that closely relate to attention deficit hyperactive disorder. Patients or children with anxiety disorders present to the hospital with symptoms such as excessive fear as well as anxiety that causes behavioral disturbances (Öst & Ollendick, 2017). The disorders do not however cause impaired functioning such as lack of attention, reduced cognitive functioning and processing, as seen in Sarah.

The fourth differential diagnosis for Sarah is autism. Autism is a spectrum disorder that is neurodevelopmental in nature. Children with autism spectrum disorder present with symptoms such as deficits in social interactions and communication, as wel as restricted repetitive pattrns of interests, behaviors and activities. Sarah is however least likely to be suffering from autism because there is lack of obsession in things that she lacks and does not recall things or details easily. Children with autism experience communication issues such as difficulties in expressing their thoughts and emotions, does not respond or initiate social interactions, and fixate on a topic during a conversation (Baribeau et al., 2020). Sarah does not demonstrate such communication inabilities, hence, making autism the least likely diagnosis for her.

Reflections:

Assessing and diagnosing patients with neurocognitive and neurodevelopmental disorders may be a challenge to psychiatric mental health nurse practitioners. Patients with the above disorders present with symptoms that may be closely related to a number of neurodevelopmental or neurocognitive disorders. Comprehensive history taking and performing diagnostic investigations is therefore recommended. It can be seen from the selected case study that Sarah is highly likely to be suffering from attention deficit hyperactive disorder, predominantly inattentive type. The symptoms of the client align with those of the disorder. Consequently, the focus of treatment should be on improving the attention span of the client alongside her social and academic performance. There is also the need to prioritize the ethical considerations that will influence the selected treatment options for the client.

 

 

References

Baribeau, D. A., Vigod, S., Pullenayegum, E., Kerns, C. M., Mirenda, P., Smith, I. M., Vaillancourt, T., Volden, J., Waddell, C., Zwaigenbaum, L., Bennett, T., Duku, E., Elsabbagh, M., Georgiades, S., Ungar, W. J., Zaidman-Zait, A., & Szatmari, P. (2020). Repetitive Behavior Severity as an Early Indicator of Risk for Elevated Anxiety Symptoms in Autism Spectrum Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 59(7), 890-899.e3. https://doi.org/10.1016/j.jaac.2019.08.478

Fumeaux, P., Roche, S., Mercier, C., Iwaz, J., Bader, M., Stéphan, P., Écochard, R., & Revol, O. (2020). Validation of the French Version of Conners’ Parent Rating Scale–Revised, Short Version (CPRS-R:S): Scale Measurement Invariance by Sex and Age. Journal of Attention Disorders, 24(12), 1693–1700. https://doi.org/10.1177/1087054717696767

Öst, L.-G., & Ollendick, T. H. (2017). Brief, intensive and concentrated cognitive behavioral treatments for anxiety disorders in children: A systematic review and meta-analysis. Behaviour Research and Therapy, 97, 134–145. https://doi.org/10.1016/j.brat.2017.07.008

Sadek, I., Mekky, A., & Elsheikh, M. (2020). Study of Depression in Attention Deficit Hyperactive Disorder Subtypes in sample of children patients. Al-Azhar International Medical Journal, 1(8), 152–156. https://doi.org/10.21608/aimj.2020.32627.1249

Sharma, P., Gupta, R. K., Banal, R., Majeed, M., Kumari, R., Langer, B., Akhter, N., Gupta, C., & Raina, S. K. (2020). Prevalence and correlates of Attention Deficit Hyperactive Disorder (ADHD) risk factors among school children in a rural area of North India. Journal of Family Medicine and Primary Care, 9(1), 115–118. https://doi.org/10.4103/jfmpc.jfmpc_587_19

Zhang, X., & Gatzke-Kopp, L. M. (2020). Exposure to Parental Aggression and

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