Case Study 2: Option 2 Stroke

Case Study 2: Option 2 Stroke

Trevor

Trevor, a 48-year old man, has been referred for neuropsychological assessment of his cognitive status 12-months post left middle cerebral artery (MCA) stroke. By way of brief background information, Trevor lives in Point Cook with his wife, Sandra (age 46), and son, Max (age 14). Prior to his stroke, Trevor worked as a furniture removalist. He enjoyed volunteering at the local football club, and was the assistant coach of his sons U16s football team. Medical history includes Type II diabetes mellitus, hypertension and hypercholesterolemia. Trevor smoked a pack of cigarettes per day for 20 years and, on average, drank 4-6 beers per night.

While at work 12-months ago, Trevor experienced sudden onset right-sided weakness, difficulty speaking, right facial droop, and confusion. He was immediately taken by ambulance to the Western Hospital Emergency Department. CT on admission confirmed a left MCA ischemic stroke. Trevor received standard acute stroke management and was monitored in ICU for the first few days and then transferred to the stroke rehabilitation unit. During his inpatient stay, Trevor received physiotherapy, occupational therapy, and speech therapy to address his motor, cognitive and communication deficits.

At 12-month follow up, Trevor continues to experience residual effects of the stroke although he has shown some degree of recovery. The right side of his body remains weak and he uses a walking stick. Mild right-sided facial droop also remains. His speech is characterised by nonfluent aphasia: speech is effortful and halting, and responses tend to be limited to 1 4 words. Cognitive assessment revealed slow processing speed (bradyphrenia) and moderate impairments to executive functions including planning, reasoning, and working memory. However, his visuospatial skills, basic attention, and memory were generally intact.

Trevors mood is low and irritable and he spends most of his time at home watching TV. Due to his physical limitations post-stroke, Trevor is unable to return to his previous occupation as a furniture removalist. The family has been struggling to make mortgage repayments due to this loss of income, and to help make ends meet, Sandra (who works fulltime as a medical receptionist) has picked up casual shifts stacking shelves at the local supermarket. With encouragement from Sandra, Trevor returned to the football club on one occasion but stated he felt useless and was frustrated by not being up to keep up with conversations. He has not returned to the football club since. Sandra is worried about Max, noting he feels sad and disappointed that his dad no longer attends his footy training and matches. She became teary when she explained that Max has had to grow up quickly, taking on extra responsibilities around the house (e.g. cooking dinner for the family while Sandra is at work) and sometimes attending appointments with Trevor when Sandra cant get time off work.

Based on Trevors symptoms, indicate which areas of the brain are likely to have been affected by his left MCA stroke.

Considering the information from the case study and using Eriksons theory of psychosocial development as a framework, describe the implications of the lived experience for Trevor and his family.

Case Study 2: Option 1 Major Neurocognitive Disorder

Mabel

Mabel, a 72-year old woman, has been referred for neuropsychological assessment by her GP due family concerns of memory decline. By way of brief background information, Mabel lives alone in Sunshine, where she has lived for the past 40 years. Mable has 12 years of education and is a retired Legal Secretary. Previous medical history includes osteoarthritis and hypertension. The following history was provided by Mabels daughter, Kelly (aged 47).

Kelly reported first noticing a change in her mothers memory approximately 12-months ago, after the death of her father/Mabels husband of 49 years, Gary. Kelly initially noticed her mother was repetitive in conversations, sometimes had trouble thinking of the right word, and would occasionally misplace her keys and glasses around the house. She also reported her mother having trouble remembering and keeping appointments, and taking her medications at the prescribed times. At first, Kelly attributed these memory lapses to normal aging and grief, but her concerns grew when they became more and more frequent. Examples of Mabels recent memory problems include calling Kelly multiple times a day and seemingly having no recollection of their earlier conversations, forgetting to pay bills, and forgetting to attend GP appointments. Kelly also suspected some impairments in visuospatial processing; she reported Mabel had a fall in her backyard three weeks ago because she misjudged the height of the step. Kelly also noted Mabel became confused and disoriented while walking home from the local milk bar last week. Mabel also calls out and searches for her late husband Gary around the house. When she is reminded of Garys death, Mabel is confused and sobs. Kelly stated, its as if shes hearing the news of his death for the first time, every time. This is very distressing for Kelly and the rest of the family.

With regard to activities of daily living, Mabel is able to perform her personal tasks (e.g. showering, toileting, dressing) independently. However, Kelly noticed that Mabel was not doing the laundry as often as she used to, and tended to wear the same clothes for three to four days at a time, even if they had stains on them. Kelly explained that in her younger years, Mabel was meticulous about her appearance; however, she now seems apathetic and less concerned about this. Mabel is also no longer interested in her previous hobbies of knitting and gardening. Kelly has been visiting Mabel 4-5 times per week to help with domestic tasks including washing, cooking, and cleaning. Kelly also does the grocery shopping for Mabel and has set up direct debits for all her bills.

Kelly described feeling stressed and exhausted by her mothers increased care needs. Until recently, Kelly was working full-time as a Social Worker but decided to reduce her hours to part-time two months ago because she was struggling to keep up with work, caring for her mother, and her childrens school and after-school activities. Kelly explained this has placed her family under financial strain, but she felt this was their only option as they could not afford paid help, and were still on a waitlist for home help through the council and My Aged Care.

Using information from the case study to support your response, identify the relevant DSM-5 criteria that support Mabels diagnosis of Major Neurocognitive Disorder.

Considering the information from the case study and using Eriksons theory of psychosocial development as a framework, describe the implications of the lived experience for Mabel and Kelly.

APP3037 Case Study: Persistent Depressive Disorder (Dysthymia)

Alan is 70 years of age and lives with his wife Joan, also 70 years old, in regional Victoria. Both Alan and Joan retired from work in their early 60s due to increasing problems with their health and mobility. Alan initially enjoyed retirement and spent much of his time engaging in his hobbies, such as reading, doing jigsaw puzzles, gardening, and watching documentaries on his favourite topics. Alan and Joan also went on a number of interstate and international holidays together in their early years of retirement. However, due in part to further deterioration in his health and mobility, and in part to diminished financial resources, Alan and Joan are no longer able to go on holidays, and even day trips are difficult. They now live a very quiet life in relative solitude with few social connections. Alan and Joan have a son and daughter who are in their 40s. Both are married and have two children each, all under the age of 10. Due mainly to geographical distance, Alan and Joan see their children and grandchildren only once or twice a year.

Five years ago, Alan began to experience poor mental health which has persisted to the present day. He reports low mood and motivation, and a sense of apathy, most of the time on most days. He goes to bed early at night and doesnt rise until the late morning the following day, and sometimes not until the afternoon. Alan also regularly overeats and consumes large amounts of junk food, and has gained a considerable amount of weight as a result. Although Alan still engages in some of his hobbies, he does so in a somewhat robotic and habitual way, and reports not getting much enjoyment out of them. He no longer does any gardening due to the ongoing decline in his physical health and mobility. In the five years since these experiences and patterns began, Alan has rarely been happy or cheerful; only very occasionally will he smile or laugh. During social interactions he comes across as withdrawn and distant. He doesnt often contribute to group conversations in any active way, and when spoken to in these contexts, Alan sometimes appears to snap out of a trance and needs the other person to repeat what they said because he hasnt been concentrating on the conversation.

Joan has become increasingly worried about Alan over the years, but also frustrated and discontent. She reports that Alan never feels like doing anything and that she feels bored and lonely in their marriage. The children have regular phone contact with Joan but are reluctant to call Alan because he rarely seems to feel like talking, and always seems in a hurry to end the conversation. Any attempts to engage him or cheer him up are usually met with a brick wall, as Joan and the children describe it. Although Alan was happy and excited when his grandchildren were born, he now struggles to connect or engage with them and usually prefers to sit in the background whenever he sees them.

Upon Joans insistence, Alan was recently assessed by a psychologist and was diagnosed with Persistent Depressive Disorder. Before this, Alan had been uninterested in getting psychological help; when reflecting on his experiences, he would simply say, This is just what life is like now; not much I can do about it and not much point trying. Further, when reflecting on his life overall, Alan reports feeling as though he never did anything important or valuable with his life, and that now its just a waiting game until the end.

After reading this case study, respond to the following:

Identify the relevant DSM-5 criteria that support Alans diagnosis of Persistent Depressive Disorder (PDD), using information from the case study to support your ideas.

Considering the diagnosis of PDD and using Eriksons theory of psychosocial development as a framework, describe the implications for the lived experience of Alan as well as his wife, children, and grandchildren.

Depressive disorders pose a particular challenge to older people, especially after retirement. Physical and cognitive decline can also compound psychological problems during this stage of life. Using at least 4-6 references, discuss and critique the literature regarding the presentation and experience of depressive disorders in older populations (i.e., >60 years old), along with implications for treatment of depression in older populations.