The central nervous system (CNS) adapts to the presence of alcohol and loses the ability to function normally in its absence, in patients who are dependent on alcohol, resulting in CNS hyper excitability. Chronic alcohol use results in the loss of homeostasis in neurotransmitter pathways and receptors in the CNS (Ray et al, 2020). There is a decrease in the number of inhibitory gamma-amino butyric acid (GABA) receptors (down regulation), and activation of the (up regulation) glutamate N-methyl-d-aspartate (NMDA) receptors resulting in an excitatory effect. Dopamine, which is a neurotransmitter, is increased and may lead to hyper excitability and hallucinations.
The brain adapts to alcohol after repeated exposure by altering opiate receptor sites requiring higher alcohol amounts to have the same feeling resulting in cravings and an increase in the number of NMDA receptors. Symptoms of having hypoglycemia can be the same as those of having alcohol withdrawal syndrome. These symptoms may include: impaired coordination and cognitive ability which may results in falls otherwise known as falls, blurred vision and slurred speech. These symptoms usually appear within a few hours to a few days after cessation of alcohol consumption, although in some patient’s signs and symptoms may develop up to 10 days after the last drink. In Mr. Willie's case this might have been the result and therefore it was important to know if there are any signs of alcohol withdrawal syndrome (AWS).
Diabetes is a risk factor for developing dementia especially in the elderly. Dementia can be both of vascular and neurodegenerative etiology. Insulin regulates neurons in the Central Nervous system and affect Ameloid Beta metabolism which accelerated Alzheimer's disease among other diseases. Patient with type 2 Diabetes may show decline in executive function in case they suffer cognitive dysfunction and also decline in learning, memory, psychomotor efficiency and attention (Munshi, 2017). Diabetes management requires the input of the patient, especially in measuring the sugars, regulating the insulin, recording changes and
managing their diet. Cognitive functions are therefore important. The risk factors for the condition may include: glycemic control, hypoglycemia, inflammation, depression and vascular pathology. Aging factors should also be considered in assessment for cognitive functions since mild cognitive dysfunction in many older individuals who are on a simple diabetes regimen may remain unrecognized and may not interfere with self-care (Glynn & Drake, 2017). In Mr. Willie case it was important to assess cognitive function because of his age, 71, above the age of 65 one has a risk of developing dementia. His cognitive abilities are very important in the self management of diabetes. It might have led to his fall due to impaired coordination.
It is said that ‘young people trip, but old people fall’. With age, muscle strength is lost and postural reflexes become impaired (Munshi, 2017). Falls are therefore common in old age, especially in the very old. Several causes may coexist. Even a single fall should lead to a detailed history and examination, and a corroborative history sought from spouse or friends. In a patient who was previously well, a search should be made for new acute illness. If none is present, the fall may be deemed ‘accidental’ due to environmental or mechanical factors, although this is a diagnosis of exclusion. Information about the pattern of any previous falls can be helpful: frequency, relationship to posture, activity or time of day, prewarning and residual symptoms following the fall, and any avoiding steps taken by the patient should be ascertained.
The absence of any warning implies a sudden event, usually neurological or cardiovascular in nature. Sinister symptoms associated with falling include loss of consciousness (although, notoriously, this is poorly reported), focal neurological deficit, features of seizure, chest pain, palpitations or other cardio respiratory symptoms. The most useful clinical investigation in older fallers is to watch them walking. Patients may also require 24-hour ambulatory electrocardiograph monitoring, a CT head scan. In Mr. Willie's case it was important to know what was the cause of the falls so that underlying factors can be treated and avoid reoccurrence.
Difficulty to perform one or more activity of daily living is what leads to functional impairment. These activities include:
a) Bathing which is determined by the ability to administer own drugs
b) Dressing which is determined by the ability to do own shopping.
c) Toileting which is determined by the ability to prepare meals.
d) Transfers which is determined by the ability to make phone calls
e) Grooming which is met when one can drive and transport
f) Feeding which may include handling own finances, doing the laundry and housekeeping.
Impairment of these activities is a risk factor for nursing home placement, emergency room visits and deaths among the elderly. It was therefore important to know if Mr. Willie can support himself or need assistance even in management if diabetes and meeting his day to day activities.
Diabetic condition in the elderly increases the risk of substantially suboptimal nutrition which may be adversely associated with cognitive impairment. A dietary pattern that includes carbohydrates is encouraged for good health but at the same time it should be monitored either by counting, exchanges or experience- based estimation (Glynn & Drake, 2017). They are encouraged to consume a diet full of fiber. They should limit their saturation fat to less than 7percent of their required calories and dietary cholesterol to less than 200mg per day. If taking fish it should include two or more servings with exception of commercially served fishletes (unsaturated fats should be avoided). Thing with protein is that it can increase insulin response without increasing the blood plasma glucose concentration; important point for hypoglycemia. Alcohol should be consumed with foods and also reduced to moderate consumption rates. Alcohol may not have an effect in blood glucose or insulin but when taken with food it may increase blood glucose.
It was therefore important to assess nutrition since Mr. Willie is diabetic and also to check for cases of malnutrition. It is also important for drug- food interaction.
Basing on the medication that Mr. Juongolo was taking which included: Aspirin, perindopril, metformin and GTN tablets, medication might have been the cause of fall. When taking aspirin one should reduce intake of alcohol, and if he or she has diabetes it's advised that they should inform their doctor. One of the side effects of Aspirin is feeling dizzy which might have resulted in the instability thus the fall (Whalen, 2018). Perindopril is an ACE inhibitor and as well, it might cause dizziness if taken with other hypertensive drugs. While taking metformin one is advised not to take alcohol as it increases blood glucose and increase your chances of lactic acid acidosis. Some of the side effects of this drug may include muscle weakness, dizziness, light- headness, very weak.
This could lead to instability this the fall. First I would refer the patient to a pharmacist to review the drug given. The drugs can be discontinued, substituted or the dose will be adjusted keeping in mind the state of the patient. In this case the patient will need the drugs since Aspirin is needed for the unstable angina; perindropril is needed for hypertensive and metformin for diabetes. The drug should be adjusted and may be supplemented by nutritional back up. Therefore we will need the nutritionist to recommend the correct dietary requirements for our patient. Since the medication may not be stopped the family members will be educated on how to respond whenever one is experiencing a fall. From the hip injury will request a physician for a physical therapy and consult.
In addition to using a patient sitter and if necessary move the patient to nursing station to meet the get assistance. It's important to try to wean off the patient from alcohol and any other drug that may worsen his condition (Kumar et al, 2017). Including a careful documentation and communication of the root cause of the fall will help prevent reoccurrence if the fall in the patient. Among some of the preventive measures to a fall; which will come after the patient have been stabilized and seen by the physician ; will include: taking simple steps for example avoiding slippery floors, help the patient manage his condition. Remind them to take the medication as prescribed by the doctor.
Always help them hydrate and also use the washroom well, do that they avoiding spilling urine and slide on them, ensure the patient eat well as recommended by the nutritionist. For the patient, he may need help with his eyesight, he has cataract and may need help to avoid tripping over things on his way. Of importance is to notice if they have difficulty with movement which may include: walking, rising from a chair, turning while in bed and any other type of movement. Talk about his medication to help him cram and remember them well. Finally, ensure the lighting in their rooms and even the entire house is good. You may want to add grabs in the bathroom and stairs to support them.
Factors that contributes to the patient psychosocial health:
Family support: the patient has the support of the wife and the daughters. The daughter’s also has kids who seem supportive. In case he needs to drive or any other support he has family friends who are more than willing to help him out. This helps him feel loved and also cared for, which promote good mental health as well as adding to his quick recovery. However, the young daughter has cancer and this may disturb his mental peace. He sounds stable about the situation but from the drinking he might be affected a little bit. He is also trying his best not to bother the daughter with his own sickness and that might strain his freedom. He might feel insufficient to helping the daughter; he needs counseling to accept the outcome.
Self acceptance: he has accepted the fact that he is sick. He is okay with the outcome and as much as he is in pain the medication that has been prescribed works for him mostly. He feels sorry for himself that he has an additional injury to his hip but he sound okay with that since he still have the support from the family.
Future plans: the patient doesn't want to experience another fall again. He must have been traumatized and disturbed. The pain and the injury to the right hip might have been the reason behind all this. It's important that the medical staff assure him that he won't experience the same fall to reduce his anxiety levels. He should also be taught of any preventive measures that can be taken to ensure that he doesn't go through the same torture again. His family should be brought on board for education purposes too, and being that they sound supportive already, they should be assuring to take care of him.
Coping mechanisms and social support network to promote the patient psychosocial wellbeing:
With the injury to his right hip, the patient will need to be stabilized. He will need to sleep in a supine position whenever he's tired of sitting. The family should therefore be taught on how best to get stabilized (Munshi, 2017). The grandchildren should be warned too not to hurt their grandfather but they can be an important tool to his mental health. He needs to keep busy and ensure that he doesn't give room to over thinking and anything else that can mess up with his mental stability. The friends too should learn how to cope with this. For instance they can enjoy dinner together as a way of showing love. The daughter should be well taken care of so that the father doesn't have to bother himself with giving his best for her.
The patient should trust the family members and be assured that they are going to take care of him. The patient should observe all the nutritional recommendation given by the nutritionist and any other adjustment given by the pharmacist to the dosage of his drugs. The patient may need to stop drinking beer completely as it might have been a contribution to the fall. He should also be told all the side effects by the pharmacist. The patient may need to visit a counselor once in a while and also frequent his diabetic clinic for checkups. The counselor will help him cope with the condition and also help me devise new ways to living a healthy and normal life. The patient should also visit an eye clinic to be checked for since he has a developing thickening of lens (cataract).
Glynn, M., & Drake, W. M. (2017). Hutchison's Clinical Methods E-Book: An Integrated Approach to Clinical Practice. Elsevier Health Sciences.
Kumar, V., Abbas, A. K., & Aster, J. C. (2017). Robbins basic pathology e-book. Elsevier Health Sciences.
Munshi, M. N. (2017). Cognitive dysfunction in older adults with diabetes: what a clinician needs to know. Diabetes Care, 40(4), 461-467.
Ray, L. A., Grodin, E. N., Leggio, L., Bechtholt, A. J., Becker, H., Feldstein Ewing, S. W., ... & MacKillop, J. (2020). The future of translational research on alcohol use disorder. Addiction Biology, e12903.
Whalen, K. (2018). Lippincott illustrated reviews: pharmacology. Lippincott Williams & Wilkins.
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