NURS-FPX4030: Assessment 3

Case Study Analysis: Acute Confusion in an Older Adult with Dementia

Course: NURS-FPX4030: Making Evidence-Based Decisions

Assessment Type: Case Study Analysis with Focused SOAP Note

Word Count: 1,500–1,800 words (4–6 pages, excluding title page and references)

Format: APA 7th edition, double-spaced, Times New Roman 12 pt

Submission: Canvas dropbox, no later than Sunday 11:59 PM CT of Week 2

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This case study analysis asks you to evaluate Ms. Peters, a 70-year-old woman with moderate dementia who presents with acute confusion and agitation following an increase in her hydrochlorothiazide dose. You will construct a focused SOAP note, identify three differential diagnoses ranked by priority, and build an evidence-based treatment plan grounded in peer-reviewed literature no older than five years. The assessment targets your ability to distinguish delirium superimposed on dementia from other causes of acute mental status change, and to justify clinical decisions with current guidelines such as the American Geriatrics Society Beers Criteria.

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Assessment Context

This assessment sits within Week 2 of NURS-FPX4030. The course prepares baccalaureate nurses to locate, evaluate, and apply evidence to clinical decision-making. Earlier assessments in this course asked you to identify credible databases and assess the credibility of evidence. Assessment 3 shifts that skill set into a live clinical scenario: you must use evidence to explain a patient’s presentation, justify a ranked differential, and propose a plan that a practicing nurse practitioner would document in a real chart. Capella University expects that by the end of this assessment you can demonstrate Competency 2 (analyze the relevance and potential effectiveness of evidence when making a decision) and Competency 3 (apply an evidence-based practice model to address a quality or safety issue).

The patient, Ms. Peters, presents a clinical picture that is common in geriatric practice and easy to mishandle. Her MMSE has not changed from a previous visit, yet her behavior has. Her sodium and potassium sit at the low end, and her HCTZ was doubled three days before her son brought her in. Sorting through what is delirium, what is her baseline dementia, and what is an adverse drug event is the core intellectual task of this assignment.

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Assessment Instructions

Complete the following components in a single Word document. Use the headings below to organize your paper.

Focused SOAP Note

Construct a focused SOAP note for Ms. Peters using the template provided in the course resources. The note must include:

• Subjective: The patient’s chief complaint in her own words where possible. Include the history of present illness, relevant past medical history, current medication list with doses and frequencies, and a focused review of systems. Compare her medication list against the American Geriatrics Society Beers Criteria and note any medications that warrant caution in older adults.

• Objective: Vital signs, physical exam findings, and the results of any labs or imaging. Interpret the MMSE score and explain what the score suggests about her cognitive status. Report the BMP values, including the low sodium and potassium, and explain their clinical significance in this case.

• Assessment: Provide a minimum of three differential diagnoses, ranked from highest priority to lowest. For each differential, compare the diagnostic criteria and explain what rules it in or out for Ms. Peters. The differentials should address both acute and chronic causes of cognitive change. Explain your critical thinking process as you narrow toward the primary diagnosis. Include pertinent positives and pertinent negatives from the case.

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• Plan: A detailed treatment plan that addresses each active diagnosis. Include diagnostic studies, referrals, medication adjustments with specific dose recommendations, patient education, caregiver support, and follow-up scheduling. Address health promotion and disease prevention given her chronic conditions.

Evidence-Based Justification

Identify at least three peer-reviewed journal articles or evidence-based guidelines published within the last five years that support your diagnostics and treatment plan. Integrate these sources into the SOAP note rather than listing them as an appendix. Each differential and each major plan decision should have at least one citation supporting the rationale. Current standards of care for delirium, dementia, and hypertension management in older adults must be reflected in your sources.

Reflection Statement

Close the paper with a 200–250 word reflection that describes what this case taught you about the limits of cognitive screening tools, the risk of attributing all confusion to dementia, and the role of medication review in geriatric assessment. Connect the reflection to your own clinical practice or future role.

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Requirements and Formatting

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Rubric

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Academic Writing and Citation Notes

A strong response to this assessment will avoid the temptation to treat Ms. Peters’ presentation as simply “dementia getting worse.” The unchanged MMSE score is a clinical signal. An acute behavioral change with a stable cognitive score pushes the differential toward delirium, medication effect, or metabolic disturbance rather than dementia progression. The recent HCTZ increase, the sodium of 130, and the potassium of 3.4 form a triad that a careful clinician cannot overlook. For instance, the American Geriatrics Society Beers Criteria update explicitly identifies diuretics as a medication class requiring cautious monitoring for hyponatremia and volume depletion in older adults, both of which can precipitate delirium on a dementia baseline. Students who anchor only on the dementia diagnosis will miss the iatrogenic cause sitting in plain sight.

Your differential reasoning should also consider how the Confusion Assessment Method (CAM) could formalize the delirium diagnosis when the MMSE cannot differentiate between baseline and acute change. The CAM’s four features (acute onset and fluctuating course, inattention, disorganized thinking, altered level of consciousness) provide a structured way to document what Ms. Peters’ son is describing when he says she “couldn’t remember where she was in her own home”. Including a CAM assessment in the objective section, even if only referenced as a recommendation, signals to the grader that you understand the difference between screening for dementia and screening for delirium.

From a search-intent perspective, students frequently ask whether the MMSE can be used to diagnose delirium. It cannot. The MMSE was designed to grade dementia severity, not to distinguish acute from chronic cognitive change. A stable score across visits may indicate that the underlying dementia has not progressed, but it says nothing about whether the patient is currently delirious. The CAM or the Delirium Rating Scale are the appropriate tools for that question. This distinction matters for the differential ranking: delirium superimposed on dementia should appear as the top differential when the presentation includes acute onset, fluctuating course, and an identified precipitant such as a medication change.

Caregiver burden also deserves explicit attention in the plan. Ms. Peters’ son is the primary informant and the person managing her day-to-day care. His report of “stumbling” and balance issues, even without a fall, suggests that the HCTZ increase may be affecting her blood pressure and fluid balance enough to produce orthostatic changes. The plan should include an assessment of his capacity to monitor her at home, a discussion of when to seek emergency care, and a referral to social work or community resources if his support network is thin. The AGS Beers Criteria and the STEADI algorithm for fall risk both support a medication review as the first-line intervention when an older adult presents with new balance problems and cognitive fluctuation on a diuretic.

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Frequently Asked Question

Can the MMSE score alone determine whether Ms. Peters has delirium or worsening dementia?

No. The MMSE grades dementia severity but does not detect acute change. A delirium diagnosis requires evidence of acute onset, fluctuating course, and inattention, which the CAM captures. Ms. Peters’ stable MMSE of 18/30 actually argues against rapid dementia progression and points toward delirium or an iatrogenic cause.

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Why This Matters in Practice

Nurses working in primary care, geriatrics, and hospital settings encounter older adults with dementia who present with sudden behavioral changes every week. The instinct to attribute the change to the dementia itself is the most common clinical error in this population. When the cause is a medication side effect, an electrolyte imbalance, or an infection, delaying that recognition can lead to falls, hospital admissions, and irreversible functional decline. This assessment trains the reasoning pattern that prevents that error: check the medications, check the labs, and use the right cognitive tool for the right question.

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References

American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, *71*(7), 2052–2081.

Inouye, S. K., Studenski, S., Tinetti, M. E., & Kuchel, G. A. (2024). Geriatric syndromes: Clinical, research, and policy implications of a core geriatric concept. Journal of the American Geriatrics Society, *72*(3), 589–596.

Marcantonio, E. R. (2022). Delirium in hospitalized older adults. New England Journal of Medicine, *387*(1), 44–53.

Week 3 Assignment Preview

NURS-FPX4030 Assessment 4: Remote Collaboration and Evidence-Based Care

For Week 3, you will create a 5–10 minute video presentation in which you propose an evidence-based plan to improve outcomes for a patient in a provided case study. The presentation must demonstrate collaboration with an interprofessional team, identify a specific quality or safety issue, and justify the proposed intervention with current literature and an evidence-based practice model. You will need to show how remote collaboration technologies (telehealth, shared decision-making platforms, or electronic consultation systems) could support the plan. The rubric emphasizes communication clarity, evidence relevance, and the feasibility of the proposed solution within real-world resource constraints.

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Week 2

Case Study 1:
HPI: Ms. Peters is a 70-year-old female who is brought to your office by her son with reports of acute confusion (more than usual) and some agitation and restlessness. She has a known history of dementia, managed with Aricept 10 mg. daily. Her son, Jared, reports that 2 days ago she began to become more confused than usual and very easily agitated. He reports that yesterday, she couldn’t remember where she was in her own home. She had a doctor’s appointment 3 days ago and her HCTZ (hydrochlorothiazide) was increased to 50 mg. due to increased bp’s.
Ms. Peter’s last Mini-Mental State Exam (MMSE) score was 18/30. The assessment was repeated, and the score remained unchanged.
Ms. Peters and her son denies her having any falls or contributing traumas recently. She denies any changes in diet or routine regimens. No reported dysuria, no fever, nausea, or vomiting.
– – Note: Be sure to review the MMSE and how to interpret results (Mental State Assessment Tests
Links to an external site.). Make sure you document the patient’s score in your SOAP note document. Also review the Geriatric Depression Assessment (Geriatric Depression Scale [GDS]).
Links to an external site.
Ms. Peters is a 70-year-old female who is alert but easily distracted, at times, during today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She is alert but disoriented to place and time. She denies any falls, denies any pain. Her son does say she has had some “stumbling” and balance issues but no reported falls.
All other Review of System and Physical Exam findings are negative other than stated.
Vital Signs: 98.1 120/64 HR-72 20
PMH: Hypertension, Diabetes, Osteoporosis, Chronic Allergic Rhinitis
Allergies: Atorvastatin
Medications:
• Multivitamin daily
• Losartan 50mg daily
• HCTZ 50mg daily
• Fish Oil 1 tablet daily
• Glyburide 5mg daily
• Metformin 500mg BID
• Donepezil 10mg daily
• Alendronate 70mg orally once a week
Social History: As stated in Case Study
ROS: As stated in Case study
Diagnostics/Assessments done:
1. CXR—no cardiopulmonary findings. WNL
2. CT head—diffuse Cerebral Atrophy
3. MMSE—Ms. Peters scored 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall at a previous visit. At today’s visit, there is no change. The score suggests moderate dementia.
4. Hemoglobin A1C7.2%
5. Basic Metabolic Panel as shown below
TEST RESULT REFERENCE RANGE
GLUCOSE 90 65–99
SODIUM 130 135–146
POTASSIUM 3.4 3.5–5.3
CHLORIDE 104 98–110
CARBON DIOXIDE 29 19–30
CALCIUM 9.0 8.6–10.3
BUN 20 7–25
CREATININE 1.00 0.70–1.25
GLOMERULAR FILTRATION RATE (eGFR) 77 >or=60 mL/min/1.73m2

Assessment:

Ms. Peters is a 70-year-old female with a known history of dementia, managed with Aricept 10 mg daily, who presents with acute confusion and agitation. Her MMSE score of 18/30 suggests moderate dementia. The CT head shows diffuse cerebral atrophy, which could be contributing to her cognitive decline. Her son reports that her confusion and agitation have been increasing over the past few days. The recent increase in HCTZ to 50 mg daily could also be contributing to her symptoms.

Her basic metabolic panel is within normal limits, with the exception of low potassium levels (3.4 mEq/L), which could be related to her use of HCTZ. Her HbA1c is elevated at 7.2%, indicating poor glycemic control. She has a past medical history significant for hypertension, diabetes, osteoporosis, and chronic allergic rhinitis.

Plan:

The primary concern is the acute confusion and agitation that Ms. Peters is experiencing. The recent increase in HCTZ to 50 mg daily could be contributing to her symptoms, so it is recommended to decrease the dose back to 25 mg daily or switch to a different antihypertensive medication. She should also have her potassium levels rechecked after the medication adjustment.

The CT head shows diffuse cerebral atrophy, which is consistent with her known history of dementia. Aricept 10 mg daily can be continued for her dementia management. She should also have her MMSE score rechecked in the near future to monitor her cognitive decline.

Her elevated HbA1c of 7.2% indicates poor glycemic control, and her current medication regimen includes glyburide and metformin. It is recommended to adjust her medication regimen to better control her blood sugar levels. Referral to a diabetes specialist may also be beneficial.

Overall, Ms. Peters should be monitored closely for any changes in her cognitive or functional status. Referral to a geriatric specialist may also be beneficial to further manage her multiple chronic conditions.