Part 1: Mr. YY, your 75 year old male patient presents to a routine check-up with concerns about his memory. He has been aware of a declining short-term memory (not being able to recall names of people, movies or recent events). Mr. YY is under a lot of stress as his wife was recently diagnosed with dementia and he is her primary caregiver. Mr. YY has hypertension, dyslipidemia, T2DM, and insomnia. His current medications include: lisinopril 40 mg daily, atorvastatin 20 mg daily, metformin 500 mg bid, and zolpidem 5 mg nightly. This week your first post is to differentiate between normal memory loss, dementia, Alzheimer’s and delirium including screening tests plus include one of the following in your discussion: 1. Explore other etiologies of cognitive changes that might be present in the older population, Mr. YY such as psychosocial, pharmacological and other system decline. 2. What are the implications of cognitive decline in the older patient for a clinician in care management? Part 2: Mr. YY had changes in medical care plan and is doing well for a short while. His last visit, he was near baseline. Today you observe on his visit that he is less engaged and hygiene is lacking. Mr. YY is not leaving his house to events that he used to like to attend. He also had a fall last week and only tells you when you notice all of the abrasions on his arm. Based on his presentation, what might you be concerned about? You suspect that he is depressed and having care-giver stress along with being isolated. 1. What would be your next steps? 2.What are the ethical considerations/care planning needed? Part 3: After several months, you are concerned that Mr. YY is not taking care of himself so how can he be taking care of his wife, who is also your patient? You ask him to bring her in for a check-up. Mrs. YY is a bit older than her husband at 79. On Mrs. YY’s check-up you note she is frail, disheveled, and has bruises over her lower extremities and arms. Mrs. YY assures you she is fine and adamantly wants to stay home. She tells you that you would have to “shoot her first” before she went to any retirement home. Mr. YY recently let go of a home-health aid he hired as she was “just sitting there staring at us.” Her medical problems include arthritis, hypertension, and allergic rhinitis. Current meds include: ASA 81 mg daily, lisinopril 20 mg daily, and diphenhydramine 50 mg each bedtime. 1. Identify any red flags in this scenario regarding complexity of medical care and psychosocial issues. 2. What might be your next actions? Ethical concerns? 3. Name some communication strategies you might employ with Mr. and Mrs. YY to discuss advance care planning and coordinating a home safety plan?


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