A Patient:
Sex: F
Age/Date of Birth: 1946
Diagnosis: Adipositas Permagna; COPD; Arterial Hypertension; Paroxysmal atrial fibrillation; Urinary Track Infection; Endogenic Depression; Massive Urinary Incontinence and Diabetes Mellitus II.
Patient was admitted with a body weight of ca. 107.0Kg
Patient is always agitating, becoming very difficult to approach and sometimes a behaviour that might affect her medical and care plan.
Patient lost two closed family members withing two years (husband and son) consecutively. Suffered these great loss and perhaps could not mourn enough.
Patient is often confronted with unpaid bills which also often makes her get wilder and very much difficult to attend to.
Patient requests almost double meals as well as late meals and fruits at night. When these requests are not met, her anger is triggered with scolding behaviour.
Patient continuously increasing in weight, her urinary incontinence almost out of management because she never followed the procedures to a better incontinence management. Hygiene sometimes very poor as a result of infectious urine dropping around in her room.
Patient´s weight was regularly weight and eventually found that she has amassed ca. 140.5Kg.
Patient was calmly, but seriously advised to check and reduce her weight, by taking more calories and stop taking late night meals.
What could be the possible cause of sudden and acute outburst of Aggression. quarrelsome and not wanting to cope with medical and care plans?
Are there any useful and applicable evidence based care plan that could be applied to care for this patient?
Totally agree with Lawrence on the need to check out all possible physical causes first. Since you are identifying depression then I'm assuming motivation to follow advice is low so I would want to focus on simple things that the patient 'wants' to do rather than things they 'should' do. (This might temper the hostility a bit also).
Are there any short term ' rewards' that could be built in to accompany steps to self-manage the incontinence for example? Are there any ‘just as good’ other activities that could replace the late meals? There are signs that some people respond well to some of the various health monitoring/mood monitoring apps that help them to map and work on their own health issues so that might be a possibility, although it isn’t an approach that suits everyone. The aggression could have a host of sources including a bereavement reaction but its always worth considering if there is an unacknowledged pain management issue (for example in relation to the urine infection).
A budget management plan can help with bills but its also possible that creditors can be approached direct. In the UK utility suppliers will work with changing tariffs or energy consumption schemes that can reduce bills or negotiate a smaller and more manageable regular payment. In the UK I have found voluntary sector agencies that will do a full financial assessment and help to develop debt recovery plans often an excellent source of help with this.
A lot of the patient’s behaviours will trap her in a cycle of social isolation so It might be an idea to frame the care plan around the larger objective of reducing social isolation, with then the patient being help to frame small self- managed steps on the way to reducing social isolation, getting out and about more , etc.
I agree with the above that this patient medical work up needs to be complete and as informative as possible, a full problem list then developed, prioritized and interventional strategies and barriers to affecting care identified. I think it critical that we in medicine move to a collaborative model, rather than working within the old compliance or no compliance model.. This would mean involving the patient in the discussion on concerns, but I have significant concerns for this particular patient's cognitive/functional status and question whether she may have chronic delirium related to her medical issues, or a frank dementia developing. Newer onset depression, if validated, would be a risk factor for and with dementia. The loss of family members over the last two years may be unmasking functional difficulties related to a neurodegenerative process. Therefore, she can no longer pay her bills in a timely fashion, manage her medications; may not be cooking appropriately and feeding instead on simple higher calorie foods/snack foods. Is she making it to appointments as scheduled, or having more difficulties? Is she having difficulty with driving, refilling medications? She presents with a very frontal lobe type picture--more impulsivity for exmple, excessive snacking), impaired judgment/reasoning and therefore all efforts to "reason with or convince" her of a need to do something fails. Aggression or agitation can arise, again a frontal type presentation, when one's ability to understand is easily overwhelmed with complex information; and when lack of insight doe not allow one to recognize a problem. Mood and cognition both can factor into agitation or aggression as well, need further evaluation.
. Has a home assessment been done? She strikes me as a perfect candidate for full team evaluation--doctors, PT/OT, social work, and most importantly, a visiting nurse. Having someone in the home to help implement interventions, provide ongoing education/counseling; and provide an assessment of home function and environment would be of utmost priority from my perspective. Certainly a baseline cognitive screening should be done, repeated at intervals to determine whether stable, improved or declining that would suggest a more neuro-degenerative process.
Agreed that depression can be from chronic illness and pain, but if treated and functional difficulties persist, a dementia would have to be considered, whether Alzehimer's or some other would still have to be considered.
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