Mrs. Ellyn Townsend is an 87-year-old widow who lives alone with her cat in a modest apartment in the center of a large city. She has lived alone for 20 years, following the death of her husband of 40 years from a fatal stroke. She has lived in this neighborhood since she and Mr. Townsend first married. They raised four children in the apartment Mrs. Townsend still occupies. The neighborhood is not as safe as it once was, but many older people have stayed in the area because of its convenient proximity to the downtown shopping area. Recently, the neighbors called Mrs. Townsend’s daughter, Theresa, to tell her that Mrs. Townsend was wandering around the neighborhood looking for her husband. Mrs. Townsend expressed concern that he was late getting home from work. When reminded that Mr. Townsend died 20 years ago, she became very agitated and argumentative. She accused the neighbors of misunderstanding her and trying to make fun of her. Although her concern about the rising crime rate in her neighborhood is warranted, she has become hypervigilant about locking doors and windows. Mrs. Townsend has various health problems, including heart disease and circulation problems attributed to her late-onset diabetes. She is on almost a dozen different prescription medicines, although it is obvious to Theresa that she does not understand when and how to take them. She becomes irritated when Theresa asks her about her medications, insisting she is taking them as required and can prove it. Mrs. Townsend is a retired nurse and until recently was very skilled in monitoring her blood sugar and giving herself insulin. She needs to be reminded how to do this now. Theresa has noticed recently that the house smells of urine and feces, and she has found soiled clothes stuffed in drawers and under the bed. Her mother denies there is a problem, refusing to consider she might need an adult hygiene product. The cat runs away frequently, and Theresa suspects that this is because her mother is either not feeding the cat or has become abusive.
1. What symptoms does Ellyn Townsend exhibit that suggest she might have depression dementia, or delirium? Which symptoms are clearly a change from what her daughter has seen in her mother over the years? 2. What immediate issues should the social worker address for Ellyn’s safety and well-being? 3. What might be the next step in developing an intervention for her? Who else does the social worker need to involve in the diagnostic process?
Personality/Behavioral Changes: Becoming agitated and argumentative when challenged about her memory or medications; showing irritation toward her daughter.
Paranoia/Hypervigilance: Excessive, unwarranted concern about crime and aggressive locking of doors/windows, stemming from poor reality orientation.
Symptoms Suggesting Delirium
Non-Specific: While no acute, rapid fluctuation is noted today, the large number of prescription medications and the obvious non-compliance (polypharmacy and medication error) create a very high risk for a drug-induced delirium or an acute confusion superimposed on chronic dementia.
Symptoms Suggesting Depression
None Clearly Evident: Mrs. Townsend's symptoms are largely cognitive and behavioral (memory loss, paranoia, agitation), not primarily mood-related (like persistent sadness or anhedonia). However, depression often co-occurs with the onset of dementia and should be screened for.
Clear Changes from the Past
The symptoms that represent the most significant and alarming change, given her history as a competent adult and nurse, are:
Loss of Professional Skill/Judgment: Inability to manage her medications and monitor her diabetes, tasks she was "very skilled" at as a retired nurse.
Loss of Basic Self-Care and Home Management: The presence of urine/feces odor, denial of the problem, and hoarding of soiled laundry.
Acute Memory Loss of Major Life Events: Forgetting her husband died 20 years ago and actively searching for him.
2. Immediate Safety Issues
The social worker must prioritize issues that pose an immediate risk of harm to Mrs. Townsend, her cat, and her health.
Sample Answer
Mrs. Townsend's case presents a classic picture of age-related cognitive decline, with features pointing strongly toward dementia. Her immediate safety and medical compliance are critical concerns.
1. Symptoms and Changes
Mrs. Townsend exhibits a range of symptoms indicative of significant cognitive impairment, primarily suggesting Dementia.
Symptoms Suggesting Dementia
Memory Impairment (Confabulation): Wandering around looking for her husband, believing he is late from work, and arguing when corrected, despite his death 20 years ago. This is a severe failure of long-term memory retrieval and reality testing.
Executive Dysfunction/Loss of Skills: Inability to properly manage her complex medication regimen (understanding and timing) and loss of ability to monitor her blood sugar and administer insulin, despite being a retired nurse. These tasks require high-level cognitive skills.
Impaired Judgment and Hygiene: Soiled clothes hidden in drawers, strong odor of urine/feces, and denial of the problem. This reflects a severe breakdown of self-care and judgment.
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