Case Study: Does this Cherokee Woman Have Dementia?

[TheMoonisMyLantern, ADN, LPN, RN]

What is her mental orientation status? 

I would want to do MMSE (Mini Mental Status Exam) to support or exclude neurocognitive decline

Full lab work up CBC, CMP, UA +CS to rule out UTI

I'd like Chest X-ray to rule out pneumonia

I feel that the "plant people" may be a cultural reference versus a delusion. I would ask her child if they perhaps understand the reference. I would encourage family involvement if their dynamics are conducive to that. Maybe her child could come visit her during a meal to help encourage her to eat.

What are her most recent set of vital signs? 

Are there any significant assessment findings? lung sounds, urine characteristics, etc.

I feel that getting to the right diagnosis with her is going to be done by excluding other conditions.

[DCdaughter, ASN, EMT-P, CRNA]

How long has she been taking Celexa? Dose?
How long has her provider been mixing it with Nexium and an NSAID? Does she have a history of diabetes?

I'd like to withhold all three of her meds, however, she is at risk for discontinuation syndrome with stopping the citalopram cold-turkey. She needs to taper off the Celexa as quickly and safely as possible, but I'd withhold the other two meds indefinitely.  

She needs a BGL, CBC, CMP, liver enzymes, and renal workup. I want to know her K+ and Na levels. She also needs a 12-lead, I want to see her QT interval.

As a Native myself, I'm certain I know what the cultural shortfall in her treatment has been. I believe dementia is at the bottom of the list of possible medical diagnosis right now. 

[kswick]

I want a head CT to see if any damage from head trauma, cbc, CMP, and UA.

I would try to find out what foods she previously ate and offer them. Most likely weight loss due to lack of eating vs other etiology. 

She is clearly depressed, understandably so give all her losses. 

[CommunityRNBSN, BSN, RN]

I don’t have much to offer medically, but the thing about “asking for weird TEAS” is easily addressed. If she asks for a specific type of tea, maybe the cafeteria staff can write it down and it can simply be ordered off the internet (once the provider checks to be sure it isn’t something that would impact her negatively). Perhaps having a small need met would be a first step in gaining her trust and making headway to her care. 

It keeps capitalizing t e a s because it thinks I’m talking about the TEAS examination. LOL!

[SafetyNurse1968, BSN, MSN, PhD]

So many great suggestions! Here is some of the information you requested. The patient had a CT scan after her fall and it was negative. If I have missed any of your questions - please don't hesitate to ask again!

Delirium vs. dementia

Dementia is the loss of cognitive functioning—thinking, remembering, and reasoning—and behavioral abilities to such an extent that it interferes with a person's daily life and activities. These functions include memory, language skills, visual perception, problem solving, self-management, and the ability to focus and pay attention. Delirium is an acute state of confusion. The diagnosis of delirium is based on clinical observation of behaviors and cognition - no diagnostic tests are available.

To diagnose dementia, doctors first assess whether a person has an underlying treatable condition such as abnormal thyroid function, normal pressure hydrocephalus, or a vitamin deficiency that may relate to cognitive difficulties. A thorough assessment is incredibly important as well as lab values and medication reconciliation.

Review of Systems: only abnormal values presented:

• Skin: poor turgor
• Abdomen: slight distension, underactive BS
• Extremities/Muscles: tenderness in hands bilaterally, subnormal strength and limited range of motion in both lower extremities, patellar crepitus of both knees.
• Mini mental: 26 points

Vital signs:

• BP 100/55 sitting, LA
• HR 85 regular
• RR 16
• T 98.6oF
• HT 5’ 10”
• WT 150 lbs
• BMI 22.1

 

Laboratory Test Results (normal range):

• Na 138 meg/L (135-145)
• K 4 meq/L (3.5-5)
• Cl 104 (101-112)
• HCO3 26 mg/dL (22-32)
• BUN 18 mg/dL (8-20)
• Cr 0.9 mg/dL (0.6-1.2)
• Glu fasting 100 mg/dL (60-110)
• Ca 9 mh/dL (8.5-10.5)
• TSH 3.7 uU/mL (0.4-6)
• FT4 16 pmol/L (9-24)
• PTH 35 pg/mL (11-54)
• Hb 13.3 g/dL females (12-15.5)
• Hct 42.5% females (35-45%)
• Plt 220,000 cu/mm (150,000-450,000)
• WBC 8.8 x 103/mm3 (4,800- 10,800)

Urinalysis:

• Dark yellow urine, clear, offensive smell
• Specific gravity 1.034
• pH 6
• Negative leukocyte esterase, nitrites, ketones, bilirubim, uroglobin, glucose, protein, bacteria, WBC or RBC

 

The patient is extremely private about her toileting. When asked about bowel movements, though she had been telling the aids she has a bowel movement every day, she admits that she has been having difficulty moving her bowels. She says she feels bloated and has gone a week without a bowel movement.

Further discussion reveals that she has only been eating dry toast, cereal and mashed potatoes for meals.

Cultural Competency (This information is from resources on the internet - I am not Cherokee. I look forward to any corrections you might offer if I've made any mistakes. Thanks in advance)

Exploring the patients’ culture may provide clues for how to support healing.

The Cherokee Nation has more than 300,000 tribal members. Cherokee are one of the indigenous people of the Southeastern US. Their homelands included southwestern North Carolina and parts of TN, SC, GA and AL. Many were forcibly relocated to Arkansas and Oklahoma in the 1800s. Between 1838-1839, over 16,000 Cherokee were forced to march to Oklahoma – a migration known as the Trail of Tears and as many as 4000 died along the way.

In traditional Cherokee medicine, Cherokee priests were consulted about not only medical problems but psychological issues as well. Herbal remedies include boneset tea, wild cherry bark, wild carrot blossoms, feverwort and pennyroyal tea. Other interventions include massage, moxibustion, dreamwork, ceremonies and calling upon the spirit world. A source of Cherokee medical knowledge is the plants themselves. Traditional Cherokee beliefs include the plant people, who give of themselves, so humans have what they need for food and medicine.

The traditional Cherokee grieving process can involve up to 10 months of mourning. Historically, during this time the widow did not bathe, comb her hair or wear new clothes. When her friends believed she had mourned enough, they would come and assist her in bathing, dressing and washing her hair.

What resources or interventions could you utilize to support this patient for her optimal health?

• Cherokee Medicine: https://www.legendsofamerica.com/na-cherokeemedicine/#:~:text=Cherokee Medicine,-Like numerous other&text=Some common herbs used by,was used in a tea.
• Cherokee funerary rites: http://www.cherokeebyblood.com/Cherokee_by_blood/Funerary.html#:~:text=Male relatives put ashes on,was to bury the death.
• Cherokee medicine: https://www.aaanativearts.com/cherokee/cherokee-medicine.htm#:~:text=Cherokee medicine (nvwoti) is an,1.

[SafetyNurse1968, BSN, MSN, PhD]

FINAL POST

This patient is not demonstrating any signs or symptoms consistent with delirium or dementia. What she does have is chronic constipation related to immobility, dehydration and lack of fiber. These things might seem easy to address on a superficial level, but when you take cultural issues into consideration, treating this patient becomes complex.

Chronic constipation is defined as infrequent bowel movements or difficult passage of stools that persist for several weeks or longer. Treatment depends on the underlying cause, but in some cases a cause is never found.

Signs and symptoms of chronic constipation include:

• Passing fewer than three stools a week
• Having lumpy or hard stools
• Straining to have bowel movements
• Feeling as though there's a blockage in your rectum that prevents bowel movements
• Feeling as though you can't completely empty the stool from your rectum
• Needing help to empty your rectum, such as using your hands to press on your abdomen and using a finger to remove stool from your rectum

Constipation may be considered chronic if you've experienced two or more of these symptoms for the last three months.

Treatment may involve diet and lifestyle changes, exercise, laxatives like fiber supplements, stimulants, osmotics, lubricants, stool softeners, enemas and suppositories.

The SNF was able to engage a nutritionist who is also a member of the Cherokee tribe. Talking with someone from her culture helped the patient begin to trust that the facility has her best interests in mind. The nutritionist spoke with food services and they were able to obtain some herbal TEAS that were evaluated by the pharmacologist for compatibility with her medications and her current health. The patient began to drink tea several times daily, which resolved her dehydration. The patient was placed on cascara segrada and a psyllium fiber supplement. The patient was willing to take the supplements when the nutritionist explained that both supplements come from plants. A final intervention was to put the patient in touch with some of her husbands’ friends and her daughter who all encouraged her to end her formal grieving process. They held a Zoom session in which they let her know she had mourned enough. A final intervention involved introducing the patient to the head of the grounds crew. She became involved in the garden plot at the facility and was instrumental in planting a Cherokee herb garden. This got her moving and helped improve her mood as well.

References

Constipation: https://www.mayoclinic.org/diseases-conditions/constipation/symptoms-causes/syc-20354253

Cherokee Medicine: https://www.legendsofamerica.com/na-cherokeemedicine/#:~:text=Cherokee Medicine,-Like numerous other&text=Some common herbs used by,was used in a tea.

Cherokee funerary rites: http://www.cherokeebyblood.com/Cherokee_by_blood/Funerary.html#:~:text=Male relatives put ashes on,was to bury the death.

Cherokee medicine: https://www.aaanativearts.com/cherokee/cherokee-medicine.htm#:~:text=Cherokee medicine (nvwoti) is an,1.

The difference between delirium and dementia: https://www.crisisprevention.com/Blog/Difference-Between-Dementia-and-Delirium#:~:text=The differences between dementia and,on one idea or task.

What is dementia? https://www.nia.nih.gov/health/what-dementia-symptoms-types-and-diagnosis

[allnurses Admin Team]

Once again, THANK YOU @SafetyNurse1968

The following are the guesses/diagnoses/rationales from members who came to the Help Desk during the "Does this Cherokee Woman Have Dementia?" 11th Case Study Investigation (CSI).

EXCELLENT job everyone!

NurseScribe

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The first issue that comes to mind is culture shock. The reference to "Plant People" is not dementia. It is a Cherokee spiritual tradition. I would contact the family in Oklahoma to ask about her spiritual needs and what kind of foods she prefers. If there are any local Cherokee tribe members they would be a good resource to help this woman adjust to what must seem like a very foreign situation. She could probably use a visit from them if it could be arranged.

It would take time to build trust with her to where she felt comfortable making requests about food and activities. If she is requesting herb TEAS they would need to be cleared by the doctor because they can interact with some medications. Fortunately she is not taking very many.

At the very least I would ask for a UA to rule out UTI, CBC to rule out anemia, an assessment for vertigo. Also a physical therapy assessment to rule out any underlying physical issues. From the documentation she appears to be getting up very little. She may be in pain.

 

kswick

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I am thinking TIA that may have been why she was falling at home. She may have sustained a concussion or small bleed when she hit head. The rest is just the sequela of that. The not eating is that she is not getting foods that she usually eats.

Probably not taking her meds, wants her TEAS as this is her cultural medicines. she is depressed for good reason, she has been taken out of her environment and this has caused further confusion and depression.  

 

spotangel

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Questions

1- Why is this patient talking about "Plant People"?

The patient is from one of  Oklahoma Cherokee tribes who consider plants as food and medicine. Women were the keepers of this knowledge and it is common to heal oneself with plants in her culture. It is what she learned as a child, knew as a woman and part of her long term memories of her life. So the plant people could be healers.

2- How would you approach a diagnosis for this patient?

Head to toe assessment, vitals, neuro exam, MMSE or Picture Based Memory Screening Examination for dementia check, labs, CT Head if none done after the fall.

Celexa has been linked with increased risk of dementia and should be tapered off. An alternative should be given if necessary

3- What strategies will you need to use for patient centered care?

Diet-more plant based. Corn is an important part of her diet with cultural significance.

Ask her about what plants are for food, what are medicinal and use them to help her. They can be substituted for  the pills.

Some of the commonly used plants are yarrow for wound healing and GI issues.

Black cohosh used as anti-inflammatory, diuretic, sedative, and antitussive activities.

American witch hazel infusions (TEAS) for periodic pains, to treat colds, sore throats, and fevers.

American ginseng can be used to improve memory and give a sense of calmness.

Involve her daughter in routines she had at home or rituals she did.

4- What labs do you want?

CBC, BMP, PT/PTT, TYPE AND SCREEN, LFT, LIPID PANEL, ESR, serologic tests for syphilis, vitamin B-12 and red blood cell folate levels, urine analysis and culture and thyroid function tests.Look for drug interaction and a toxicology screen. Weight loss in the absence of nutritional deficits should be worked up for cancer.

5- What other diagnostic tests should we run?

If required, LP for CSF infection

_______________

Labs look OK. CT head OK. Has she be assessed for depression PHQ2/ PHQ7 versus grief and mourning?

The meds can cause delirium and long term dementia and so must be stopped. 
The constipation should be addressed with laxative TEAS. She needs to also be given water on a schedule along with salads from the plant people. If she is negative for depression and continues to have symptoms after the meds are stopped, I would go for dementia work up but it would be a diagnosis of exclusion. The team should be culturally competent about her culture, values and beliefs to give her optimal care.

 

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