New Mexico Geriatric Education Center

1. Polypharmacy

Case study of a 66 year old, American Indian male, who is currently in a long-term off-reservation treatment facility status-post a left below the knee amputation. He has had long-standing insulin dependent diabetes mellitus. Questions for discussion include social/cultural considerations, medical concerns, cultural meaning of an amputation, medication use, his health belief system, his concept of disease, his concept of therapy and healing, and cultural, social and spiritual issues surrounding amputation and use of a prosthesis. This is a sample of questions and is not all inclusive. This case study is designed to be used by physicians, nurses, pharmacists and social workers.

Twelve pages

 

2. Normal Aging

-Josephine Cato Objectives:
1. Differentiate between normal and abnormal aging.
2. Prioritize health promotion and preventive activities which would benefit the patient’s quality of life.
3. Analyze and propose realistic implementation plans for environments and dietary concerns that are health risk factor for Josephine.
4. Compare and contrast the cultural beliefs of the providers with those of the clients to indicate how these beliefs work within the current system.
 

Case study of a 72 year-old woman having pain in her knees and back and not going out as much as she used to.


This case study is designed to use with students from medicine, nursing, pharmacy and social work. It explores the social/cultural considerations of interviewing, her cultural values and beliefs, communication issues, cultural conflict of the professional and the client, and family issues.


Ten pages

3. Mrs. Roval

Case study of a 76 year-old female who lives alone in a northern New Mexico pueblo. It discusses establishing a relationship with the client, communication issues related to hearing, vision, and thinking difficulties, the role of the CHR, assessing the client and family strengths, cultural issues, and services available in the community.

This is designed for use with Community Health Representatives or other caregivers in the home.

Six pages divided into five parts.

4. Depression


History of Present Illness
Mrs. Sylvia Vasquez had become very concerned about her mother, Mrs. Beatriz Apodaca, when she did not participate in making food for the Pueblo Feast Day. She seemed withdrawn when people came to the home for the feast. Mrs. Vasquez persuaded her 68 year old mother to go to the clinic at San Felipe Pueblo. Since Mrs. Apodaca spoke primarily Keres, the traditional language, her daughter served as the translator. She explained to the clinic internist that her mother had been complaining of more body aches and frequent stomach pains for several months. Mrs. Vasquez said that her mother had not felt well since the death of her father two years ago. He had died of pancreatic cancer after a lengthy illness. Shortly after her father’s death, Mrs. Vasquez explained that she and her three children moved into her mother’s two-bedroom home. She added that her 15 year old son was causing her mother a great deal of stress as he had started drinking and staying out late. Mrs. Vasquez notes that her mother is not eating well; she refuses most food and has lost 10 lbs. in the last four months. She goes on to say that in the evening, she goes to bed early and seems to sleep restlessly. Her mother no longer is visiting friends and does not enjoy going out. She has even stopped going to the Senior Center. Mrs. Vasquez states that her mother has become more forgetful recently, even forgetting how to prepare familiar foods.

Past Medical History
Mrs. Apodaca has a 2-year history of documented hypertension treated with _______________.

Family History
Mrs. Apodaca had six children. Two have IDDM, one son committed suicide at age 23.

Social History
Mrs. Apodaca lives with her 34 year old daughter and her three children ages 15, 11, and 7. Two of her other children live on the Pueblo, one son lives in Albuquerque and another son is in the military. Her small home lacks running water and she and her family must haul water daily.

Physical Exam/Mental Status
BP 150/90

General: Mrs. Apodaca is a frail looking woman who sits quietly during the interview with her head down.

Mouth: poor dentition with many missing teeth
Throat: clear
Lungs: CTAP
CV: RRR, no murmurs
Lymph: no adenopathy
Extremities: swelling on PIP joints, bilaterally. 1+ non-pitting edema on both legs
Back: slight tenderness on right with muscle spasm under scapula
Abdomen: no masses, no bruits, no liver enlargement
Neurological: normal findings
Speech: She says little, even when questioned by her daughter, and only in Keres.

Mental status: Mrs. Apodaca does not know the current date; she does know the season and year. She does not know the President of the U.S., but is able to name the Governor and Lt. Governor of their Pueblo. Her daughter is asked to inquire about depression and patient denies depression. She does acknowledge difficulty sleeping at night, having a poor appetite and feeling too weak to chop her wood. When asked if she feels any hope for the future, she states, “the Creator may have some purpose for me, but I don’t know what it is.”

Questions:

Could Mrs. Apodaca be depressed? What are the cues to suggest this?

Are dates and presidents culturally fair cognitive evaluation questions? Why?

How could her mental status be assessed in a culturally sensitive manner?

Are there environmental issues that should be addressed?

How would you acquire more information to address “stomach” complaints?

What significance do GI disorders have on drug therapy in this age group?
  1. Dementia in the elderly in an American Indian population.
  2. Depression in the elderly in an American Indian population.

 

5. LTC Community Based

FACILITATOR INFORMATION

Overview
This is a case study of an Indian elder who lived alone on a pueblo north of Albuquerque until he became so physically and mentally frail that he was no longer able to take care of himself. With help from his only remaining relative, a nephew, who felt he was unable to provide services as a caregiver, he was admitted to an Albuquerque nursing facility. In the nursing facility he felt isolated, mostly because his primary language was Keresan. His ability to speak and understand English was limited. He eloped several times from the nursing facility and was found wandering in the neighborhood. He indicated he was trying to find his way back to the pueblo where he had lived most of his life. The patient has had diabetes for 20 years and been managed with oral hypoglycemics.

Expected Learning Issues
  (This is for the facilitator only. This will be revealed to learners at the END of the case.)

 
LEARNER

Patient Presentation
Alberto Baca is an 82 year old Pueblo Indian male who has resided in Ladera Nursing Facility in Albuquerque for the last two months. You are seeing him at the request of Adult Protective Services (APS), who became involved with his situation during one of his elopements from the facility. You are asked to provide an evaluation by the nursing facility administrator as to whether it is feasible for him to return home.

His medical records reveal a history of diabetes mellitus of at least 20 years duration. He has received care for this condition at an Indian Health Service Clinic and has been treated with oral hypoglycemics. Over the last five years he has lost weight from 180 pounds to 130 pounds and taken his medication for diabetes only sporadically. The most recent fasting glucose concentrations off medications ranged from 130 to 180 mg% (Normal 80 -115 mg%).

Mr. Baca had been living in a small home on the Pueblo until admission to the nursing facility. It had electricity and a pump from the well supplied water. He used an outhouse located 100 feet behind the house. Heating was provided by a wood stove in the kitchen area; the wood stove was also used for baking and cooking food. He had a small, inexpensive microwave oven. It was clear that Mr. Baca rarely left his home except to use the outdoor facilities. Entertainment consisted of watching the television.

Mr. Baca’s only source of income is social security; he is enrolled in institutional Medicaid, which has been paying for the nursing home stay. The only relative the nursing home and APS are aware of is a nephew who lives in the Pueblo. At the time Mr. Baca was admitted to the facility, the nephew felt he had too many other obligations to serve as a caregiver to his uncle. The nephew helped with arrangements for his uncle’s admission to the nursing facility, stating that Mr. Baca had grown too frail to take care of himself on the reservation and that “his memory was going.”

Members of the community were not included in the arrangements to move Mr. Baca to a nursing facility in Albuquerque and were upset because Mr. Baca clearly didn’t want to go. The community members felt that, although conditions were much less than optimal, he would still be better off at home. However, they felt it was not their decision to make, therefore, did not express an opinion to the nephew. Mr. Baca’s house had been empty since he was moved to the nursing facility. The community felt it still might be possible to move him back to the Pueblo and develop a support system for him there.

Mr. Baca speaks Keresan as his primary language and has limited ability to understand and speak English. He has not communicated with any of the other residents in the nursing facility. On two or three occasions, he “eloped” and was found wandering in the neighborhood with all his belongings stuffed into 2 pillowcases. He indicated he was going home to the Pueblo.

When you interviewed Mr. Baca, he was reluctant to open up and say much about how he felt about his situation until you asked him whether he would rather live in his old home or in the nursing facility. He was adamant that he wanted to return to his old home and live there until he died.

This is clearly what he wanted to do, but the question is whether he is functionally able to do this. In addition, are caregiver services available to adequately support him in his home? What would those services cost, and how could they be paid for?

Discussion Questions
  1. How do you define Mr. Baca’s problems?
  2. How would you go about evaluating Mr. Baca’s ability to care for himself at home? Explain.
  3. Describe the cultural issues that you should consider.
  4. What additional information do you need at this time to deal with Mr. Baca’s problems? Explain.
  5. What plans would you make for communicating with Mr. Baca? What plans are you going to make to communicate with Mr. Baca’s nephew and Community Health Representatives (CHR) in the Pueblo?
  6. Is Mr. Baca able to decide his fate? How do you know and what are you to do?
Past Medical History and Health Practices

Mr. Baca had a diagnosis of diabetes made over 20 years ago in an Indian Health Service clinic in the Pueblo and was started on an oral hypoglycemic agent. At that time, he was obese and was given a diet to reduce weight. He took his medications appropriately until five years ago, but has taken them only sporadically since. He has lost weight from 180 to 130 pounds.

Mr. Baca has had no other significant medical illnesses, surgeries, or injuries. He has no known allergies. He has neither a living will nor any advance directive documents. The nephew has spoken with him about these issues. What questions do you have for the nephew?

Family History

Mr. Baca does not know what his parents died from, but they were both young when they died. He had two brothers, one living with diabetes and hypertension, and the other died from unknown causes after he left home. He was married, but his wife died 30 years ago from acute cholecystitis. He had two children, both dead, one from an automobile accident and the other from unknown causes after moving to Albuquerque.

Known Risk Factors
  Social History

The patient worked intermittently as a laborer but frequently was unemployed. He participated in Pueblo activities such as dancing until 5-10 years ago. He has had little social interaction over the last 5 years. He dropped out of school after completing the sixth grade and had no further formal education.

Review of System(ROS)

A complete review of systems was performed by a nurse practitioner who works in the nursing home; the following information was documented in the chart.

  Physical Examination
  In your case manager capacity, you perform a multidimensional assessment on this patient. Using the ADL assessment tool, it was determined that Mr. Baca was almost independent in his capabilities of providing his own personal care, being able to dress, bathe, and feed himself. Except for occasional urinary incontinence, which required either diapers or changing of clothes, there were no limitations. When using the IADL (Instrumental Activities of Daily Living), he fared less well, showing that he had no means of getting to and from a shopping center and that he had problems remembering to take his medications. He could use a phone but did not have one in his home on the Pueblo. He was able to chop and haul wood, use the outdoor toilet, and prepare food, but appeared to be apathetic about doing so.

You included a Mini Mental Status Exam (MMSE) in your assessment. Because of the language barrier and lack of education, he had problems with arithmetic, spelling and written portions. He scored a 17/30.

In your conversations with Mr. Baca, he has been oriented to place but usually does not know the date. His short-term memory appears impaired – he needs prompting to remember your name when you see him on the second day of your contact with him. He could not remember what he ate for breakfast, but he seemed to enjoy talking about some of his experiences years ago on the Pueblo. His judgment and reasoning did not seem to be impaired. When asked why he wandered off from the nursing facility to go back to the Pueblo, he stated he missed his friends there, many of whom had died. He admitted that the only persons he saw regularly were his nephew who came to visit once or twice weekly and the CHR (Community Health Representative), who stopped in weekly to check on whether he was supplied with food and other staples and to help him with paying his bills.

Interview with the nephew and community health representative (CHR) and home visit

The nephew was 46 years old with a wife and five children ranging in age from 23 years to 7 years. The two oldest children no longer lived at home on the Pueblo. They had moved to other communities. The nephew was employed in the construction business owning his own grader and truck and worked as an independent contractor primarily for one large company. This company provided him enough work that he worked essentially full-time. He owned his own home that was about eight miles away from his uncle’s home.

He said, because of his demanding work schedule, he only was able to visit his uncle about twice a week for short periods. He described the home as poorly kept up often finding food in the refrigerator that had been there for weeks and was not fit to eat. He often shopped for his uncle bringing in stores of food and staples. His uncle did not have a phone in the house. The nearest phone was in a home nearly a quarter of a mile away so he worried about what would happen if his uncle became ill and needed help. He felt his uncle had no real interests except to watch television. He was not eating appropriately and often had to be reminded to eat. He never complained but appeared to be lonely. He showed no signs of paranoia, hallucinations, delusions, obsessions or anxiety/phobia. He often stayed up late at night watching television and then slept late in the morning.

A CHR was interviewed, a 46 year old Pueblo Indian female, who had been employed in the position eight years. She had known Mr. Baca this entire time and had visited him once weekly over the last five years, less frequently prior to that. She notes that Mr. Baca has become more frail and forgetful and feels he is lonely and depressed. Many of his friends and family had died. She had been impressed by his weight loss and tried to encourage him to eat more regularly, but confirmed what the nephew said, that Mr. Baca generally had food in the refrigerator or cupboards but didn’t have regular times to eat and often left food so long that it spoiled. She confirmed that she helped Mr. Baca pay his bills and that he just seemed incapable of doing this now. She described a progressive loss of capability over the last 5 years that was partly due to a loss of short-term memory and partly due to a loss of interest or apathy.

You went with one of the Pueblo’s public heath nurses to visit Mr. Baca’s home. On arrival, you found the door locked; someone had removed all of the food that could potentially spoil. The refrigerator had been cleaned out and disconnected. It worked when tested. The wood stove which provided heat and a means for cooking and baking was in working order and appeared to be safe, but there was no supply of firewood available. The pump, which was working, emptied into the sink in the kitchen area. The kitchen area received light from a single 100-watt bulb in a fixture from the ceiling. It had appeared that someone had cleaned up the kitchen area after Mr. Baca left. The only medications found in the home were in a kitchen cupboard where a half-empty bottle of chlorpropamide, which was outdated by nearly two years, and a bottle of half-used Tylenol were found.

The main living area had an old couch and several wooden chairs with an old model television set that was in working order. The bedroom had a standard size bed with a nightstand. The sheets on the bed were very dirty as were the pillowcases. This appeared to be the only set in the home. Several blankets were on the bed. The outside latrine was in a state of poor repair having been used past the time when it should have been moved to a new site. It was unclean by most standards. There were no stairs or safety hazards such as loose throw rugs on the floors.

Discussion Questions