Advanced Applications of Home-Based Primary Care

Minerva Case

Pdf Summary

Minerva, an 86-year-old female with a history of congestive heart failure (CHF) and Alzheimer's disease, is seen post-discharge following hospitalization for CHF exacerbation accompanied by bilateral leg edema and cellulitis. She has a history of recurrent admissions for similar issues and once for urinary tract infection (UTI) related to mental status changes. Diagnosed with Alzheimer’s six years ago, her behavioral disturbances have worsened over the past 6-9 months, manifesting as increased forgetfulness, agitation during personal care, and episodes of verbal and physical aggression. Her caregiving falls mainly on her daughter, who resides with her, while her son, who holds her health power of attorney (HPOA), obtained historical information.<br /><br />Minerva’s past medical history includes heart failure with reduced ejection fraction (HFrEF, EF 35%), cerebrovascular accident (CVA), coronary artery disease (CAD), hypertension (HTN), chronic kidney disease (CDK Stage 3), macular degeneration, generalized osteoarthritis, hypothyroidism, gastroesophageal reflux disease (GERD), breast cancer (post right mastectomy), and recurrent UTIs. She has received appropriate immunizations and has mild residual dysphagia from the CVA.<br /><br />Her physical exam reveals a sacral-coccygeal stage 4 pressure ulcer, decreased breath sounds bilaterally, mild flexor contracture in the knees, and 1+ bilateral leg edema. She is minimally ambulatory and requires assistance with all activities of daily living (ADLs), making her a high-burden patient. She expresses significant mood changes with a PHQ9 score indicating depression and a Mini-Cog score of 0, showing severe cognitive impairment.<br /><br />Medications include Donepezil and Memantine for dementia, Isosorbide, Furosemide, Metoprolol for heart failure, among others. The family seeks advice on managing her conditions to avoid hospital readmissions, improving her mobility, behavior, and mood, and reducing UTI frequency.<br /><br />Key assessment areas include identifying patient and family preferences, potential mood/mentation improvement strategies, mobility aids, medication management complexity, and addressing her multicomplex health conditions through potentially helpful resources.

Keywords

congestive heart failure

Alzheimer's disease

bilateral leg edema

cellulitis

behavioral disturbances

pressure ulcer

depression

medication management

mobility aids

multicomplex health conditions