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O’Neil, Silvaggio 1

Jillian O’Neil, Lisa SilvaggioKNH 41112/5/13

Case Study #25 – Alzheimer’s Disease

1. Define dementia. Define Alzheimer’s disease (AD). How do they differ?

Dementia is a general term for loss of memory and impaired cognition, while Alzheimer’s is the

most common form of dementia, being characterized by formation of amyloid plaques in the

brain and neurofibrillary tangles within neurons (631).

2. What is the current theory regarding the etiology of AD? How is AD diagnosed?

Research has shown that the gene variant of “Apolipoprotein E” (APOE) is the risk factor of AD

in those aged 65 years or older. This gene is produced in the liver and circulated with the VLDLs

(very low-density lipoproteins) in the blood. This gene variant is found in 40% of patients with

AD in comparison to 15% of the general population. Those who have one copy of the variant are

at an increased risk of 3-4x for developing AD than those without. Research has also shown that

the presence of presenelin 1 (PSEN1), presenelin 2 (PSEN2), and amyloid precursor protein

(APP) are linked to early-onset of AD. Research is still continuing for addition gene variants. In

addition, cardiovascular disease, diabetes, free radical oxidative damage, Down syndrome and

previous head injury have had a link with the development of AD. A decreased risk of

developing AD has been linked with an increased intake of fruits, vegetables, fish and omega-3

fish oils.The DSM-IV-TR Diagnostic Criteria for Dementia of the Alzheimer’s type includes:

memory impairment and at least one of: aphasia, apraxia, agnosia, and/or disturbance of

executive functioning.

(Nelms 631)


3. Based on Mr. McCormick’s medical record, what are his other concurrent diagnoses?

Could any of these contribute to his symptoms?

He has had two myocardial infarctions and hypertension for 44 years. Although heart disease is

not directly related to AD, this does mean that his vascular system is challenged at carrying

oxygen, which could alter his mental state somewhat.

4. What are the current medical interventions available for the management of AD? What are

the goals of these interventions?

Medications are available for the treatment of AD. Second generation cholinesterase inhibitors

(ChEIs) and NMDA receptor antagonist memantine are included in this list of treatments.

Memantine antagonizes glutamine that binds to the NMDA receptor to improve cognition and

behavior. An addition treatment (being reviewed under research) is selegiline, gingko biloba,

estrogen replacement, statin, antioxidants and anti-inflammatory drugs. Reality orientation and

cognitive simulation are two nonpharmacological measures that have aided the AD patients.

Psychiatric medications can be used to treat agitation and depression – both symptoms associated

with AD.

Although there is not yet a cure for AD, treatments and interventions are available to achieve

main goals including: the understanding of this particular case, aid in the progression or

worsening of disease state, aid in the comfort of the patient, treat symptoms of the disease and

aid in activities of daily living.

(Nelms 631, 632)

5. Mr. McCormick has a Stage III full thickness nonpressure wound. What does that mean?

A Stage III full thickness nonpressure wound is when the skin develops an open, sunken hole

with full thickness skin loss and damage to the tissue below the skin but is not caused by


constant pressure to the area, but bone, tendon or muscle is not exposed (169). The surrounding

skin can be discolored and sore.

6. Describe the normal stages of wound healing?

The normal stages of wound healing are broken into three key phases – inflammatory,

proliferative and remodeling. The inflammatory stage begins at the time of injury and ends about

four to six days post-injury. During this stage, the bleeding is controlled by the coagulation

cascade and fibrin clot formation. Then, vasodilation and increased capillary permeability occurs

before the neutrophils phagocytize the bacteria. Lastly, the macrophages remove debris and

necrotic tissue as well as secrete growth factors. The second stage – proliferative – begins as the

inflammatory stage ends and continues for the next two to three weeks. During this stage, the

epithelial cells form a protective covering and framework over the wound. Angiogenesis allows

the development of the granulation tissue before the fibroblasts produce collagen and the matrix

protein with aids in the formation of these tissues. The deposition of collagen causes a cross-

linking which strengthens the wound before the myofibroblasts induce wound contraction. The

wound then begins to close as the remodeling stage begins. This stage can continue for up to two

years. The collagen matures and stabilizes before the fibrous scar tissue matures. This causes a

decrease in fibroblasts and vascularization. Unfortunately, the skin and fascia will never regain

it’s full strength when this stage is completed.

(Nelms 167)

7. Name a minimum of three factors that support wound healing. Name a minimum of

three factors that may impair wound healing. Identify the most probable factors that may

have contributed to Mr. McCormick’s poor healing.


Nutrition plays an important role in wound healing as he will need sufficient energy, protein and

fluids. His levels for the amino acids, arginine and glutamine increase, Vitamin A,C and K,

selenium and zinc are needed, and the keeping the wound clean and undisturbed will help with

the healing (167). Healing may be impaired if foreign material gets into the wound, if an

infection develops, if the skin is exposed to radiation, the elderly, those who are bedridden or

immobile, and those that have poor nutritional status. Mr. McCormick’s risk factors will most

likely be his age, being physically inactive and having low appetite which will make meeting his

nutritional needs difficult.

8. Describe the potential roles of Vitamin A, Vitamin C, Vitamin E, Zinc, Copper, Glutamine,

and arginine in wound healing.

Research has shown that Vitamin A, Vitamin C, Vitamin E, Zinc, Copper, Glutamine, and

arginine have roles in wound healing, although, further research is still needed to additionally

support these statements. Vitamin A supplementation has shown to improve wound healing

when a deficiency has been present in addition to radiation, chemotherapy or diabetes. If the

client is Vitamin A deficient or suffering from diabetes (a common link of AD), then a

supplementation may aid in the patient who is suffering from a wound. Vitamin C deficiency

can delay wound healing and thus, supplementation may be needed to increase wound healing.

Vitamin E supplementation may adversely affect the healing of certain types of wounds.

Although, topical vitamin E may aid in scar formation. Zinc aids in the maintenance of skin

integrity and mucosal membranes. Copper is required for tissue regeneration and ultimately a

progression in healing of the wound. While glutamine is the preferred energy source for

enterocytes, lymphocytes, and macrophages, it is the precursor for nucleotides and glutathione.


Arginine supplementation can be beneficial by increasing collagen deposition, improving

nitrogen balance, and enhancing several parameters of the immune function.

(Nelms 168, 169; National Institutes of Health)

9. Assess this patient’s available anthropometric data. Calculate % UBW and BMI. Which

of these is the most pertinent in identifying the patient’s nutrition risk? Why?

BMI= 138 pds / 71”^2 x 704

=0.027 x 704

=19.3 kg/m^2

His UBW is is 170 pounds

% UBW= 138/170 x100

= 81.2% UBW, meaning a loss of 18.8% body weight in the last four years.

BMI would be most pertinent, since it compares the height to the weight, even though he has lost

a reasonable amount of weight, the rate is not categorized as significant.

10. Discuss the progressive weight loss Mr. McCormick has experienced. Why is this of

concern? What factors may have contributed to this weight loss?

Mr. McCormick, as stated by his son, has usually weighed about 170 pounds (77.3 kg) until 4

years ago. He currently weighs 138 pounds (62.7kg). This is a 32-pound weight loss (14.6kg)

that has progressed over the past four years but mainly within the first year. Currently, he is

about 81% of his usual body weight meaning he lost 19% of his body weight. Factors that may

have contributed to this weight loss can include the following list. First, his altered brain function

may have affected his cognition and ultimately his feeding behavior. He may have found it

difficult to initially prepare foods and remember if he has already eaten. In addition, he may not

remember how to use utensils or that the purpose of food is to eat it. He may have experienced


chewing difficulty as well as dysphagia. Confusion and agitation can cause the feeding

difficulties. Lastly, the lifestyle transitions from his normal daily activities of living to the long-

term care facility can cause the unstable weight fluctuations.

(Nelms 632, 633; A Case Study Approach 290, 292)

11. Calculate energy and protein requirements for Mr. McCormick.

Using the Mifflin St-Jeor equation:

10 x W + 6.25 x H -5 x age + 5

(10 x 62.3 kg) + (6.25 x 180.3 cm) - (5 x 89) + 5

= 623 + 1126.9 - 445 +5

= 1309.9 kcal/day

Mr. McCormick should be consuming about 1300 to 1400 kcal a day

I would use a factor of 1.5 g/kg/day of protein because of the increased need for wound healing

and the fact he is malnourished, requiring him to consume (1.2 x 62.3 kg) about 93 g/day of

protein.

12. How would you determine the levels of micronutrients that Mr. McCormick needs?

Using Mr. McCormick’s age and gender, I would to compare and determine the levels of

micronutrients needed by assessing the dietary reference intakes (DRI). To determine the

particular essential micronutrients for wound healing table from Dr. Demling’s Research.


(Demling, National Institutes of Health)

13. Identify all medications that Mr. McCormick is prescribed. Describe the basic function

of each.

Mr. McCormick is on furosemide, atenolol, lisinopril, Zocor, haloperidol, warfarin, and

donepezil. Furosemide is used to reduce swelling and fluid retention as it causes the kidneys to

get rid of unneeded water and salt through the urine, can be used to treat high blood pressure

(“Drug info”). Atenolol is a beta blocker and relaxes the blood vessels and slows the heart rate to

improve blood flow and is used to decrease blood pressure (“Drug info”). Lisinopril is used to

treat high blood pressure and improve survival after a heart attack as an ACE inhibitor blocking

chemicals that tighten blood vessels (“Drug info”). Zocor is a statin that slows the production of

cholesterol in the body and decrease the amount of cholesterol that builds up on arteries (“Drug

info”). Haloperidol is an antipsychotic used to motor and verbal tics and controlling explosive

behavior by decreasing abnormal excitement in the brain (“Drug info”). Warfarin is a blood

thinner and helps reduce blood clots from forming and blocking blood vessels. Donepezil is used

to treat dementia associated with AD by improving mental function (“Drug info”).


14. a. Using his admission chemistry and hematology values, which biochemical measures are

abnormal?

Based on his laboratory results, Mr. McCormick has 16 abnormal chemistry and hematology

values. First, he has an increased BUN level of 22mg/dL with the reference range of 8-18mg/dL;

an increased cretainine serum level of 1.3 mg/dL with a reference range of 0.6 to 1.2 mg/dL; an

increased C-reactive protein value of 5.1 mg/dL with the reference range of <1.0mg/dl; an

increase LDL/HDL ratio of 3.67 with a reference range ratio of <3.55 for males; and an

increased WBC value of 16.0 x106/mm3 with a reference range of 2.8 x106/mm3 to

11.8x106/mm3. Is chemistry and hematology values also showed a decrease in protein with 5.5

g/dL in total in comparison to the reference range of 6-8 g/dL; a decrease in albumin of 2.9 g/dL

in reference for the normal range of 3.5-5 g/dL; a decrease in prealbumin of 14 mg/dL when

normally it should be 16-35 mg/dL; a decrease in HDL cholesterol of 33 mg/dL with the

recommendation of >45 for men; a decrease in hemoglobin with 13.5g/dL and a recommended

range of 14-17 g/dL for men; a decrease in hematocrit with a value of 39% and a reference range

for men of 40-54%; a decreased mean cell volume of 77 um2 with the reference range of 80-96

um2; a decreased mean cell Hgt value of 24 pg with a reference range of 26-32 pg; a decreased

mean cell Hgb content value of 30g/dL with a reference range of 31.5-36g/dL; a decreased value

of 165mg/dL for Transferrin when a reference range for men includes 215 to 365 mg/dL; a

decreased Ferritin value of 18 mg/mL with a reference range of 20-300 for men; and lastly, a

decreased lymphocyte value of 10% when the recommended range should include 15-45%.

(A Case Study Approach 293, 294)

b. Which values can be used to further assess his nutritional status? Explain


His nutritional status can be further assessed by evaluating his sodium, potassium, chloride,

glucose, BUN (blood urea nitrogen), creatinine, phosphate, protein, albumin, prealbumin,

ammonia, and cholesterol, HDL, LDL, LDL/HDL ratio, triglycerides. In particular when

evaluating his laboratory results on 8/12, his creatine, glucose, albumin, prealbumin, LDL and

LDL/HDL ratio. His nutritional intake can alter and have a great affect on his health status, as

indicated with his laboratory values. An abnormal lab value can indicate that changes will need

to be made with the patient’s consumption choices – regardless of deficiencies or excess

amounts.

(A Case Study Approach 293)

c. Which laboratory measures are related to his infection and wound?

An increase in his C-reactive protein level is indicative of inflammation present and a sign of

infection. A decreased value of prealbumin may also indicate a sign of infection, inflammation

and trauma. Increased levels of white blood cells may indicate inflammatory disease and

infectious diseases. A decrease in hemoglobin levels may indicate anemia, which may be caused

by a vitamin deficiency. If the deficiency is Vitamin C, there may be a delay in wound healing

(as stated in question 8). Abnormal transferrin levels may also indicate anemia. Lastly, a

decrease in lymphocytes can cause a decrease in the tissue repair process of infection and wound

healing.

(American Association for Clinical Chemistry; Medline Plus; A Case Study Approach; Schaffer)

15. Do you think this patient is malnourished? If so, why? Will this impact the success of

interventions for wound healing?

I think that this patient is malnourished, he has had poor appetite and has had difficulty with

eating. He also has had unintentional weight loss over the past 4 years, food intake is variable


and ihis overall energy and vitamin/mineral consumption is low. His lab values such as albumin

(2.9 g/dL) and prealbumin (14 mg/dL) are low, indicating he has not been getting his protein

requirements either. Since he his not meeting his energy, protein, and vitamin/mineral needs, this

will slow his wound healing, especially now that they are elevated to promote healing.

16. Identify issues related to Mr. McCormick's primary diagnosis that could potentially

interfere with his ability to consume an adequate diet.

Mr. McCormick’s primary diagnosis was, and still is, Alzheimer’s disease. This diagnosis may

cause difficulty for the development of an appetite. In addition, based on his weight loss, his lack

of desire to eat will influence his ability to consume an adequate diet. Although the foods needed

will be present at the long-term care facility, it will only be useful if he can have an appetite,

“remember” how to feed himself, and consume all of the food portioned on his plate.

17. Are residents in a long-term care facility at higher nutritional risk than elders living

independently? Why or why not?

I believe that elders living independently are at a higher nutritional risk, although it depends on

the health of the person. Most of the time, if an elder needs to be at a long-term facility, they

need some sort of help with daily life. Also, most elderly have decreased appetite anyway, so if

they are living at home, they may disregard or forget to eat. If they are at a long-term care

facility, a diet is created for them and they are given meals, even being monitored if they are not

finishing their meals consistently. Plus, if they are at a facility, more help is available if they

have trouble eating or swallowing.


18. Select two nutrition problems and complete the PES statement for each.

A. Unintended Weight Loss

· Unintended weight loss (NC-3.2) related to lack of appetite and Alzheimer’s

disease related symptoms as evidence by weight history (30 pound weight loss),

medical record (current weight of 138 pounds) and son’s statement (normal

weight of 170 pounds).

B. Self-Monitoring deficit

· Self-monitoring deficit (NB-1.4) related to Alzheimer’s disease symptoms of

dementia as evidence by requirement of special modifications to diet, assistance

with all meals and lack of independence with activities of daily living at long-

term facility.

(Academy of Nutrition and Dietetics)

19. For each of the PES statements that you have written, establish an ideal goal (based on

the signs and symptoms) and an appropriate intervention (based on the etiology).

For the unintended weight loss, an ideal goal would be to gain about 0.5 pound a week to regain

some weight back. This would require an additional 250 kcal/day making his goal for caloric

intake to be about 1550-1650 kcal/day. This could be achieved by encouraging the

high-calorie/high-protein shakes in between nutrient dense meals. For the self-monitoring deficit,

an ideal goal would be for the same one or two people to consistently bring him his meals and to

assist him with eating them. This would help because he would have a better chance of

recognizing and trusting them. Also, being served his meals and snacks at the same time

everyday could help with developing a routine, making him more likely to eat.


20. What specific dosage recommendations would you make about supplementing zinc,

copper, vitamin A, vitamin C, and arginine to promote wound healing for Mr. McCormick?

In regards of supplementation for promoting wound healing, I would encourage that Mr.

McCormick takes the following each day: 20 mg of Zinc, 2 mg of Vitamin C and 18.5g of

arginine.

(Nelms 168, 169)

21. Mr. McCormick drinks high-calorie, high-protein milkshakes at the Veteran’s home.

What products might you recommend for him during his hospitalization?

I think that continuing high-calorie, high protein milkshakes would be beneficial since he already

will drink them and are nutritionally dense. Since he has a wound, I would recommend products

with arginine and glutamine and high levels of Vitamins A,C, K , selenium and zinc such as

Pivot 1.5 Cal. This product is very high calorie (1500 kcal/1000 mL) and high protein (93.8

g/1000 mL) and contains the amino acids and vitamins needed for wound healing. It also has

50.8 g/ 1000 mL of fat to help him gain some weight back (“Abbot”).

22. What specific interventions might you recommend for a patient with Alzheimer's that

could improve his oral intake during a hospitalization?

For a patient with Alzheimer’s disease, I would encourage the entire care team take part in his

intervention process. Although we are currently concerned with his nutrition, his overall well-

being must be properly taken care of in order to have a successful intervention. As stated in the

patient’s history, he needs assistance with all meals. Thus, it would be encouraged for his “care

giver” to remain the same person or only fluctuate between two. If Mr. McCormick had a large

number of caregivers, he may have difficulty trusting the person assisting in mealtime. In

addition, I would encourage that his meals are on a schedule with a set time with a constant table


set up to avoid confusion. As also stated in his history, finger foods and accessible snacks are

offered. This can aid in the prevention of difficulty using silverware. Giving the opportunity to

eat snacks throughout the day can increase his caloric intake as well as give him some freedom

to maintain independence. If his best meal of the day is in the morning, then breakfast should be

full of calories and nutrient dense foods.

23. What measures of the adequacy of oral intake would be appropriate to use during Mr.

McCormick’s hospitalization?

I would monitor his calorie intake to see if he is meeting his goals. I would also encourage high-

protein, nutritionally dense snacks and meals to meet his elevated needs for wound healing. His

weight would also be monitored to see if there are any changes.

(A Case Study Approach 290, 292)

24. If Mr. McCormick's intake is inadequate, is he a candidate for enteral feeding? Outline

the pros and cons for recommending nutrition support for this patient. What are the ethical

considerations?

If his intake is inadequate, he is a candidate for enteral feeding. As stated in previous cases: “if

the gut works, use it.” Since it is difficult for Mr. McCormick to intake the necessary energy

intake, enteral feeding is a great option to resolve these concerns. His Alzheimer’s symptoms are

currently causing great confusion during feeding. Thus, the pros of enteral feeding for nutritional

support include giving Mr. McCormick the necessary nutrients in the exact amount for prevent

weight loss and hopefully gain back weight in addition to improving his health status when

comparing to laboratory values. Enteral feeding would also be beneficial for him because he

won’t have the issue of concern for eating. This activity of daily living would be taken care of

and cause less stress on the patient directly as well as the care team. On the other hand, a con of


the enteral feeding would be if Mr. McCormick were in charge of feeding himself. If he is

currently having difficulty feeding himself in a process he was used to his entire life then, he

may have even more difficulty feeding himself in a new way. Another concern may include the

cost of enteral feeding and the procedure to prepare the body for tube feeding. The last concern I

would have is in regards to his “combative episode” history as stated in his medical records. If he

is easily confused and agitated, a concern would be that he may try to remove the tubes attached

to his person. Lastly, ethical considerations concerning the enteral feeding process include that

he can’t independently think properly causing someone else to make the decision for him. If he

hasn’t documented that he would like to be on enteral feedings then it is difficult to decide who

should make the final call and say in his dietary future.


ResourcesAcademy of Nutrition and Dietetics (2013). International dietetics and nutrition terminology

(IDNT) reference manual: Standardized language for the nutrition care process. Chicago, IL: Academy of Nutrition and Dietetics.

Demling RH. Nutrition, anabolism, and the wound healing process: an overview. Eplasty.2009;9:65–94.

“Drugs.” Drug, Supplement, and Herbal Information. National Institutes of Health, n.d. Web 29 November 2013. http://www.nlm.nih.gov/medlineplus/druginformation.html

"Health Information." Medline Plus. U.S. National Library of Medicine, n.d. Web. 27 Nov. 2013. <http://www.nlm.nih.gov/medlineplus/>.Nelms, Marcia. Medical Nutrition Therapy: A Case Study Approach. 4th ed. Stamford,

Connecticut: Cengage Learning, 2013. PrintNelms, Marcia Nahikian. Nutrition therapy and pathophysiology. 2nd ed. Belmont, CA: Wadsworth, Cengage Learning, 2011. Print.“Pivot 1.5 Cal.” Abbott Nutrition, n.d. Web 30 November 2013.

http://abbottnutrition.com/brands/products/pivot-1_5-cal"Prealbumin." Lab Tests Online. American Association for Clinical Chemistry, n.d. Web. 27 Nov. 2013. <http://labtestsonline.org/understanding/analytes/prealbumin/tab/test>.Schaffer, M, and A Barbul. "Lymphocyte Function In Wound Healing And Following Injury." British Journal of Surgery 85.4 (1998): 444-460. PubMed. Web. 27 Nov. 2013."Zinc." Office of Dietary Supplements. National Institutes of Health, n.d. Web. 28 Nov. 2013. <http://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/>

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