Cognitive Impairment in MS A Case Study Anne Bateman, CNP, CRRN PVA Summit 2012
Disclosures/Commercial Support for this Activity: This continuing education activity is managed and accredited by Professional Education Service Group. The information presented in the activity represents the opinion of the author/faculty. Neither PESG, nor any accrediting organization endorses any commercial products displayed or mentioned in conjunction with this activity. Commercial support was not received for this activity.
Disclosures Anne M. Bateman, NP, CRRN has no financial interest or relationships to disclose. CME Staff Disclosures: Professional Education Services Group staff have no financial interest or relationships to disclose.
Learning Objectives At the conclusion of this activity, the participant will be able to: 1. Describe how cognitive and physical deficits can create a dependency relationship between a patient and his/her caregiver. 2. Identify how MS-related cognitive impairment can bring about maladaptive coping behavior in the caregiver. 3. Recognize and discuss how decision making is impaired in caregiver crisis and how this can be mitigated.
57 yr. old male EDSS 8.0 Case Study Married to German-born spouse while serving in the Army. Two college-aged sons. Home: Non-accessible split entry house Education 1.5 yrs. college, 4 yrs. trade school Employment: Union carpenter, retired for disability.
History History of alcohol abuse, tobacco use. Age 24: MS symptoms: blurred vision, fatigue Age 27: MS Diagnosis: after exacerbation with lower extremity weakness Two other exacerbations over the next 10 yrs. And continued progression of disability thereafter, including cognitive and vision deficits.
Rocky Progression 2000: Suicide attempt by overdose of Paroxetine, Neurontin, and Clonazepam 2000: Suicide gesture by superficially lacerating his wrists and legs. Beta Interferon is switched to Glatiramer Acetate for suicide attempts and ineffectiveness. 2001: Legally blind, severe executive dysfunction, increased physical impairments, falls, unable to self cath.
More Trouble at Home 2002: Suicide attempt by drinking drain cleaner, liquid cleaning products and washing it down with coffee. Depakote started for behavior Wheelchair bound, increased spasticity, dependent edema, heel wound. Patient is now overweight. Wife continues to be sole caregiver. Couple becomes more isolated due to inaccessibility of the home and his aberrant behavior. Declines home care services.
Safety Concerns 2008: Admitted for one week Caregiver Respite. Found to have multiple cigarette burn marks on bilateral thighs. Supervision and welder s apron to protect from dropped cigarettes is advised. Spouse is unwilling to stop providing cigarettes, beer and shots about 5/day. Social Services involved. I can t do this anymore. Long term placement strongly advised, spouse vacillates, eventually declines placement and home care services.
Caregiver Crisis 2009, 2010: Respite admissions notable for episodes of inappropriate sexual behavior toward nurses and angry outbursts. He is otherwise, pleasant, cooperative. Likes to watch baseball, favorite music: AC/DC Spouse continues to vacillate about long term placement and caregiver burnout I can t do this anymore. Followed closely by Social Worker. 2011: Spouse states she is no longer able to care for her husband, presents to the VA ER where he is admitted for Detox and failure to thrive. ETOH: 7 drinks/day, no withdrawal signs.
Evaluation Neuropsychological testing: confusion, disorientation and gross cognitive impairment. Behavior problems manageable with distraction and redirection in the hospital setting. MRI suboptimal due to pt. unable to lie still. Did show increased lateral and 3 rd ventriculomegaly.
Decision Making Neurologist: It is up to her whether she wants to keep him on the (Glatiramer). Eventually, the medication is discontinued because it is reasonable to stop since the patient has not had a relapse in many years. Spouse is relieved at not having to make that decision.
A Big Decision Spouse agrees to long term placement in a VA CLC.
Thoughts to Consider 1. In what ways does emotional investment, isolation, and fatigue from years of stressful caregiving interfere with a caregiver s ability to make safe decisions?
Thoughts to Consider 2. When cognitive impairment prevented informed self determination about stopping disease modifying therapy, the burden fell to the spouse. How was this decision similar to her impaired ability to choose long term placement?
Thoughts to Consider 3. A cognitive and physically disabled person is dependent upon a caregiver. In what ways did this caregiver also become disabled? Do you see this as a mutually disabled couple?
Thank you for your attention. Thank you Thank you for the excellent care you provide to our Veterans and their caregivers. Anne M. Bateman, CNP, CRRN SCI/D Center, Minneapolis VA HCS anne.bateman@va.gov
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