Care for Older People - Case Study

Running head: CARE FOR OLDER PEOPLE
CARE FOR OLDER PEOPLE
Name of the student
Name of the university
Author Note

1CARE FOR OLDER PEOPLE
Introduction
Aging is a biological process of life which is associated with physiological,
psychological, social and behavioral changes. An overall deterioration in physical and
mental functioning may result in observable and extreme alterations to the appearance, the
quality of life and emotional healthiness of older adults. Since elderly people face common
issues regarding anxiety disorders, cognitive disorder, loss of thinking capability, and
decision-making, they are worst sufferer of ageing bias and did not get proper access of
appropriate treatment and care (Murman, 2015). Ignorance behavior of nurses and lack of
interest in geriatric care leads to the older patient care more difficult (Johansson et al.,
2018). In the presented case study, Mrs. Jones, aged 85 years old, has been admitted in Dementia
Unit. It is most important to take care and support the patient with Alzheimer’s disease especially
in old age since it enhances the physical, mental and overall well-being of the patient. This paper
will discuss the pathophysiology and related with ageing theory, the impact of the illness of the
patient and associated ethical and legal issues, medications and their side effects and finally a
care model that will enhance the patient’s quality of life.
Pathophysiology of the disease and related ageing theories
Alzheimer’s disease is a neurodegenerative disorder that progresses dementia in
older people. It is an irreversible, progressive disease of brain that gradually decreases the
memory and thinking abilities of a person. The normal symptoms of the disease include
language problem, loss of memory, and unusual behavior (Bondi, Edmonds & Salmon,
2017). The damage associated with the disease mainly takes place in hippocampus site of

2CARE FOR OLDER PEOPLE
the brain which is vital for forming memories. Extracellular amyloidal protein deposition
as senile plaques and intracellular neurofibrillary tangles (NFTs) are the characteristic
features of this disease (Van Dam et al., 2016). The neuronal loss may be observed in the
region of amygdala, hippocampus, entorhinal cortex and the cortical association regions of
temporal, frontal and parietal cortices. It is also seen in the subcortical nuclei for example
noradrenergic locus coerulus, subcortical nuclei like serotonergic dorsal raphe and
cholinergic basal nucleus. One of the important pathological characteristics of AD includes the
formation of senile plaques that is triggered by deposition of amyloid beta (Aβ) (Lee, Shih &
Kuo, 2014). The Aβ are soluble small peptides which are formed from precursor protein of
amyloid. The disproportion between β amyloid production and clearance triggers
formation of various types of toxic oligomeric namely fibrils, protofibrils and plaques
depending upon the extent of oligomerization. The cause of the development of the Aβ is
unclear till now. Some factors are accountable for causing this disorder includes oxidative
stress, cholinergic dysfunction, and toxicity of amyloid / tau activity. The brain uses high
consumption of oxygen that leads the brain more susceptible to oxidative stress. The
neuron consists of large huge number of polyunsaturated fatty acids that can react with
reactive oxygen species which eventually generate molecular apoptosis and lipid
peroxidation reaction. Less glutathione in neurons is also a triggering factor of oxidative
stress injury. The tangle formation is much more related with dementia rather than
amyloid plaques. The deposition of tau proteins causes cognitive decline and brain atrophy,
including hippocampal atrophy (Abuhassan, Coyle & Maguire, 2014). In the case of
neuropathology of this disease, the loss of neurons and atrophy in temporofrontal cortex are
observed (Abuhassan, Coyle & Maguire, 2014). This causes inflammation and deposition of

3CARE FOR OLDER PEOPLE
amyloid plaques. Presence of abnormal cluster of protein fragments and tangled bundles of
fibers increases the monocytes and macrophages in cerebral cortex and also stimulates the
microglial cells in the parenchyma. In this case study, Mrs. Jones had type II diabetes,
hypercholesterolemia and COPD. Additionally she was an active smoker. All these factors
trigger the prevalence of the disease of Alzheimer in the patient. The risk factor of this disease
includes the age and the gender. Female got this disorder often rather than male and the
increased age has high risk of causing this disease (Alzheimer Society of Canada, 2020).
Many stochastic theories are present related to aging. It includes theory of error-
catastrophe, theory of mutations, theory of breaking of chemical bonds, theory of oxidative
stress, theory of DNA reparation. Many researchers have shown that AD is directly related
with aging but not specifically with the theories of aging. Apart from theory of glycosylation,
all the mentioned theories are applicable with the AD disorder. In the theory of mutations,
DNA reparation may be linked with mutagenesis of β-amyloid, presinilin, and
neurofibrillatory expression genes. The theory of catastrophe can be related with abnormal
tau protein phosphorylation and the interruption of ligation which is caused by abnormal
fracture of β-amyloid protein. The immunological model is connected with immunological
effects that is seen in aging as inflammatory process. It also found that activated astroglia
and microglia are linked with AD (Fakhoury, 2018). Among the non-stochastic theories,
programmed senescence and intrinsic mutagenesis can explain the alteration of genes which is
associated with AD. Telomere theory may be linked with depletion of genes that can also cause
AD (Trevisan et al., 2019).

4CARE FOR OLDER PEOPLE
Medication and side effects related to the chosen medical illness
The one of the two drugs that has risk of causing Alzheimer’s disorder is Temazepam. It
is the medicine that is used to treat insomnia associated with anxiety. It is under the class of
benzodiazepine. This drug increases the effect of gamma-aminobutyric acid (GABA) that is a
vital inhibitory neurotransmitter. They act as agonist at the allosteric modulatory benzodiazepine
receptor on the GABA receptors. When the BZD binds to its BZD receptor site and GABA binds
to its GABA receptor site, it forms a complex. This complex increases the rate of occurrence of
opening of the GABA central chloride channel. This elevated influx of chloride channel
enhances the inhibitory action of GABA. This, in turn, will reduce awakening and stimulates
sleep. The action starts ranging from 20 to 60 minutes and the duration of action includes
medium to long (Verma, 2016). The prolonged use of this medication can cause adverse
condition such as Alzheimers’ disease. This drug has many side effects that are linked with the
disease. The studies reported that this medication can cause rapid deterioration in cognitive
function. This cognitive dysfunction elevated the risk of Alzheimer’s disorder (He et al., 2019).
These drugs can also lead to progression of confusion, impaired coordination. Prolonged use of
this drug can affect in decreasing memory which is the crucial factor of causing Alzheimer’s
disorder (Verma, 2016).
Another drug that is directly related with dementia is metformin. It is used to treat the
patient with type II diabetes. It is used to maintain blood sugar level and inhibit kidney damage,
nerve problem, blindness, and loss of limbs. The metformin is an antihyperglycemic substance
that is used to enhance the glucose tolerance in type2 diabetes patients. It works by decreasing
both basal and postprandial plasma glucose. It can lower the hepatic glucose production decrease
absorption of glucose in intestine. Along with this, it enhances peripheral glucose utilization and

5CARE FOR OLDER PEOPLE
uptake and thus improving the insulin sensitivity. Metformin does not cause hypoglycemia in the
patients with type-2 diabetes like other drug (Rena, Hardie & Pearson, 2017). Long term use of
this metformin has been shown to elevated risk of neurodegenerative disorder in these patients.
increased blood sugar levels can damage cerebral function and the type II diabetes patients have
higher chance of dementia that is caused by Alzheimer’s disease. The mechanisms involved in
this disease include inflammation, atherosclerosis, oxidative stress, amyloid β deposition and
brain insulin resistance with hyper-insulinemia. The metformin has impact on cognitive
impairment and dementia as well as APOE gene polymorphism. The study has reported that long
term use of metformin may increase the risk of Alzheimer’s disease in the patients with age 65 or
more (Moriera, 2014).
Impact of the illness on the health of person & related ethical/legal issues
The Alzheimer disease is not a curable disease and it gradually progresses towards worse
condition. Progression of this disease leads to the situation worse. The people with this disorder
may often lead to harm themselves such as suicidal thoughts and behaviors. Since they lose the
capability of cognitive function, they are unable to communicate with others. They failed inform
their other health issues or symptoms. As a consequence, the other symptoms may remain
unassisted. Since this disorder is associated with brain, and neuron the older patient may
face difficultly in swallowing. They may possess increased risk of susceptibility to develop
pneumonia and other infections. The blood-brain barrier protects the brain by regulating the
substances by passing from the blood into brain tissue. In Alzheimer’s disease, the blood-brain
barrier is impaired particularly the brain region. The amyloid protein and ApoE4 gene,
which is connected to Azheimer’s disorder, is responsible to damage the blood-brain-

6CARE FOR OLDER PEOPLE
barrier (Alzheimer's Society, 2020). Thus, the bacteria, viruses and other harmful agents, that
are causing infection, can enter into the brain easily. Thus, the patients with this disease are more
susceptible to cause infection (Alzheimer's Society, 2020).
At the time of the patient with Alzheimer’s disease, health care professionals and
caregivers may face some ethical issues to treat the patient. The psychiatrists face the first
problem when more definitive diagnostic testing is required to confirm the disease. It is
more challenging when the patients ask for genetic screening (Guan et al., 2017). In the
middle and later stages of disease, providing care is more confusing as the patients fail to
behave properly, losses the ability to make decisions and also loses the memory. It creates a
conflict situation for the psychiatrist whether to value the patient’s autonomy or to provide
maximum treatment to enhance their life (Watt et al., 2019). Since the patients are near to death,
questions may arise about the extension of the treatment to retain the patient’s life. The doctors
often lie to the patient at the time of delivering care to the patient. This leads to another
ethical dilemma because it violates and departs from the continuing reliability that the
families have maintained with these patients (Watt et al., 2019). Though these patients are
cognitively impaired, emotional balance is still present in them. As a consequence, the patients
may loss the integrity and get angry or emotionally deprived.
Appropriate model of care/strategies/ resources to maintain quality of life
After reviewing the case study, the patient is required a model of care that enhances the
quality of care of that patient. It mentioned recovery based care. In recovery based model, all
the inconsistence of the patient is noted down one by one (Dawson et al., 2015). After that, they
are prioritized and the goal of each problem is set. For example, the person-centered care is

7CARE FOR OLDER PEOPLE
planned to improve her disabilities related with ADL (Kogan, Wilber & Mosqueda, 2016). Since
the patient has Alzheimer’s disease, the Cognitive Behavioral Therapy should be performed.
This procedure is effective for treating this order as the patient was prescribed with various
drugs. For solving her swallowing problem, feeding tube can be used to provide her proper
nutrition. Palliative care is another most important care services that provides proper
identification of the disease, pain management and other problems like physical, mental and
spiritual (Van der Steen et al., 2014). It integrates the spiritual and psychological aspects of
patient care. It also provides support system to live actively as much as possible (Palliative care
services in Australia, 2020). A team should be formed that will assist to serve the patient
whenever she will require help. Moreover, the family support will give strength to her to increase
her self-esteem or self-confidence. Nurses play a lead role in this case. They will provide all the
medical treatment, support, person-centered care and prioritize the events according to the
patient’s needs.
Conclusion
From the above paper, it can be concluded that the older patient need proper attention and
care. Old age is the sensitive stage of life where they need proper care and comfort to enjoy well-
being without any anxiety. Since the patient faces difficulties with ADL, she needs person-
centered care for assistance. The cognitive behavioral therapy will increase her coping strategies
related with Alzheimer’s disease. Moreover, the family support will provide her more strength to
increase her self-confidence. Although, the treating of elderly patients is not easy task, nurses
play a major role in providing best care to this patient. Nurses are able to provide person-
centered care and recovery based care to enhance the quality of life.

8CARE FOR OLDER PEOPLE
Reference
Abuhassan, K., Coyle, D., & Maguire, L. (2014). Compensating for thalamocortical synaptic loss
in Alzheimer's disease. Frontiers in computational neuroscience, 8, 65.
https://doi.org/10.3389/fncom.2014.00065
Alzheimer Society of Canada. (2020). Risk factors | Alzheimer Society of Canada. Retrieved 5
April 2020, from
https://alzheimer.ca/en/Home/About-dementia/Alzheimer-s-disease/Risk-factors
Alzheimer's Society. (2020). Infections and dementia. Retrieved 5 April 2020, from
https://www.alzheimers.org.uk/about-dementia/risk-factors-and-prevention/infections-
and-dementia
Bondi, M. W., Edmonds, E. C., & Salmon, D. P. (2017). Alzheimer's Disease: Past, Present, and
Future. Journal of the International Neuropsychological Society : JINS, 23(9-10), 818–831.
https://doi.org/10.1017/S135561771700100X
Dawson, A., Bowes, A., Kelly, F., Velzke, K., & Ward, R. (2015). Evidence of what works to support and
sustain care at home for people with dementia: a literature review with a systematic
approach. BMC geriatrics, 15, 59. https://doi.org/10.1186/s12877-015-0053-9
Fakhoury M. (2018). Microglia and Astrocytes in Alzheimer's Disease: Implications for Therapy. Current
neuropharmacology, 16(5), 508–518. https://doi.org/10.2174/1570159X15666170720095240
Guan, Y., Roter, D. L., Erby, L. H., Wolff, J. L., Gitlin, L. N., Roberts, J. S., Green, R. C., & Christensen, K.
D. (2017). Disclosing genetic risk of Alzheimer's disease to cognitively impaired patients and visit
companions: Findings from the REVEAL Study. Patient education and counseling, 100(5), 927–
935. https://doi.org/10.1016/j.pec.2016.12.005

9CARE FOR OLDER PEOPLE
He, Q., Chen, X., Wu, T., Li, L., & Fei, X. (2019). Risk of Dementia in Long-Term
Benzodiazepine Users: Evidence from a Meta-Analysis of Observational Studies. Journal
of clinical neurology (Seoul, Korea), 15(1), 9–19. https://doi.org/10.3988/jcn.2019.15.1.9
Johansson, Y. A., Bergh, I., Ericsson, I., & Sarenmalm, E. K. (2018). Delirium in older hospitalized
patients-signs and actions: a retrospective patient record review. BMC geriatrics, 18(1), 43.
https://doi.org/10.1186/s12877-018-0731-5
Kogan, A. C., Wilber, K., & Mosqueda, L. (2016). Person‐centered care for older adults with
chronic conditions and functional impairment: A systematic literature review. Journal of
the American Geriatrics Society, 64(1), e1-e7.
Lee, C. W., Shih, Y. H., & Kuo, Y. M. (2014). Cerebrovascular pathology and amyloid plaque
formation in Alzheimer’s disease. Current Alzheimer Research, 11(1), 4-10.
Moreira P. I. (2014). Metformin in the diabetic brain: friend or foe?. Annals of translational
medicine, 2(6), 54. https://doi.org/10.3978/j.issn.2305-5839.2014.06.10
Mueck, W., Stampfuss, J., Kubitza, D., & Becka, M. (2014). Clinical pharmacokinetic and
pharmacodynamic profile of rivaroxaban. Clinical pharmacokinetics, 53(1), 1-16.
https://doi.org/10.1186/1477-9560-11-10
Murman D. L. (2015). The Impact of Age on Cognition. Seminars in hearing, 36(3), 111–121.
https://doi.org/10.1055/s-0035-1555115
Rena, G., Hardie, D. G., & Pearson, E. R. (2017). The mechanisms of action of
metformin. Diabetologia, 60(9), 1577–1585. https://doi.org/10.1007/s00125-017-4342-z

10CARE FOR OLDER PEOPLE
Trevisan, K., Cristina-Pereira, R., Silva-Amaral, D., & Aversi-Ferreira, T. A. (2019). Theories of
Aging and the Prevalence of Alzheimer’s Disease. BioMed research international, 2019.
https://doi.org/10.1155/2019/9171424
Van Dam, D., Vermeiren, Y., Dekker, A. D., Naudé, P. J., & Deyn, P. P. (2016). Neuropsychiatric
Disturbances in Alzheimer's Disease: What Have We Learned from Neuropathological
Studies?. Current Alzheimer research, 13(10), 1145–1164.
https://doi.org/10.2174/1567205013666160502123607
Van der Steen, J. T., Radbruch, L., Hertogh, C. M., de Boer, M. E., Hughes, J. C., Larkin, P., ...
& Koopmans, R. T. (2014). White paper defining optimal palliative care in older people
with dementia: a Delphi study and recommendations from the European Association for
Palliative Care. Palliative medicine, 28(3), 197-209.
Varma, S. (2016). Benzodiazepines and hypnotics. Medicine, 44(12), 764-767.
https://doi.org/10.1016/j.mpmed.2016.09.019
Watt, A. D., Jenkins, N. L., McColl, G., Collins, S., & Desmond, P. M. (2019). Ethical issues in
the treatment of late-stage Alzheimer’s disease. Journal of Alzheimer's Disease, 68(4),
1311-1316. DOI: 10.3233/JAD-180865